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ESSENTIALS 



B S T E T E I C S 



By 
CHARLES JEWETT, A.M., M.D., Sc.D. 

PROFESSOR OF OBSTETRICS AND GYNECOLOGY IN THE LONG ISLAND COLLEGE 
HOSPITAL AND OBSTETRICIAN AND GYNECOLOGIST TO THE HOSPITAL ; 
CHARTER MEMBER OF THE CONGRES PERIODIQUE INTERNATIONAL 
DE GYNECOLOGIE ET D*OBSTETRIQUE ; FELLOW OF THE BRITISH 
GYNECOLOGICAL SOCIETY ; EX-VICE-PRESIDENT OF THE AMERI- 
CAN GYNECOLOGICAL SOCIETY; EX-PRESIDENT OF THE NEW 
YORK OBSTETRICAL SOCIETY, ETC. 

Assisted by 

HAROLD F. JEWETT, M.D. 



Illustrated by 80 Woodcuts and 5 Colored Plates 




'■> 



LEA BROTHERS & CO. 

NEW YORK AND PHILADELPHIA 

1901 






THE LIBRARY OF 
CONGRESS, 

Two CuHita Received 

OCT. 22 1901 

COPvniGHT ENTRY 

CLASS £uXXc. No. 
COPY 8. ' 






Entered according to the Act of Congress in the year 1901, by 

LEA BROTHERS & CO., 
In the Office of the Librarian of Congress. All rights reserved. 



1> 



PREFACE TO THE SECOND EDITION. 



As set forth in the preface to the first edition the 
object of this work is to place the Essential facts and 
principles of Obstetrics within easy grasp of the student. 
It is intended as an introduction to the more elaborate 
treatise, and as a guide in following the didactic and the 
practical teaching of the college course. 

Most attention has been given to practical topics. 
Theoretical discussions, matters of merely historical inter- 
est and elaboration of details have in the main purposely 
been excluded. 

Works of this character, in the author's experience, 
have, within their proper limits, a distinct value in med- 
ical teaching. The pupil in any department of learning 
needs first to master its elements. This once accom- 
plished, a complete and systematic knowledge of the sub- 
ject becomes a matter of comparatively easy growth. 

The present edition represents a complete revision of 
the work. Much has been rewritten and new matter has 
been added. 

The author will be gratified if the book in its revised 
form meets Avith the flattering reception accorded the first 
edition. 

Chakles Jewett. 
330 Clinton Ave., Brooklyn, N. Y., 
October, 1901. 



\ , 



CONTENTS. 



CHAPTER I. 

ANATOMY OF FEMALE GENITAL ORGANS. 



PAGES. 

External genitals — The vagina — Internal genitals . 17-44 
CHAPTER II. 

PHYSIOLOGY OF PREGNANCY. 

Physiology of the ovum — Effects of pregnancy on the 
maternal organism— Signs of pregnancy — Dura- 
tion of pregnancy — Hygiene of pregnancy . . 45-95 

CHAPTER III. 

PHYSIOLOGY OF LABOR. 

The mechanical factors of labor — Clinical and me- 
chanical phenomena of normal labor — Manage- 
ment of labor ....... 96-170 

CHAPTER IV. 

PHYSIOLOGY OF THE PUERPERAL STATE. 

Course and phenomena of the puerperal state — Man- 
agement of the puerperal state — Lactation and 
nursing — The child — Condition at birth — Manage- 
ment of the newborn child — Artificial feeding — 
Disorders of the newborn infant . . . . 171-206 



vi CONTENTS. 

CHAPTER V. 

PATHOLOGY OF PREGNANCY. 

Diseases of the deciduse — Anomalies of the amnion 
and the liquor amnii — Disease of the chorion — 
Anomalies of the placenta — Anomalies of the um- 
bilical cord — Pathology of the fetus — Abortion — 
Premature labor — Ectopic gestation — Pernicious 
vomiting and other disorders of pregnancy . . 207-239 

CHAPTER VI. 

PATHOLOGY OF LABOR. 

Anomalies of the mechanism— Anomalies of the ex- 
pelling powers — Anomalies of the passages — 
Anomalies of the passenger — Anomalies of labor 
arising from accidents or disease .... 240-313 

CHAPTER VII. 

PATHOLOGY OF THE PUERPERAL STATE. 

Puerperal insanity — Galactorrhea — Mastitis — Puer- 
peral infection . . . . . . .314-329 

CHAPTER VIII. 

OBSTETRIC SURGERY. 

Induction of premature labor — Induction of abortion 
— Removal of an abnormally adherent placenta 
— Forceps — Version — Csesarean section — Porro 
operation — Symphysiotomy — Embryotomy . . 330-378 



ERRATA. 

Page 22. Kobalt should read Kobelt. 

Page 192. Gauge should read gauze. 

Page 192. Forbe's should read Forbes'. 

Page 193. Sterilized gruel should read dextrinized 

gruel. 
Page 194. (Sugar two tablespooufuls) should read 

sugar (two tablespooufuls). 



ESSENTIALS OF OBSTETRICS. 



CHAPTER I. 
ANATOMY OF FEMALE GENITAL ORGANS. 

For convenience of description the genital organs of the 
female may be divided into the external and the internal 
genitals, and the vagina, which connects the one group with 
the other. 

The external genitals of the female together constitute 
the pudendum, all but the mons veneris, the vidva. 

External Genitals. 

The external sexual organs of the female are the mons 
veneris, the labia majora, the labia minora, the clitoris and 
the hymen. 

The Mons Veneris, or the mount of Venus, is the 
fleshy prominence which overlies the anterior aspect of 
the pubic bones. Its surface is slightly convex. It is 
bounded laterally by the groins, above by the hypogastric 
fold, and below it merges into the labia majora. It consists 
essentially of fat supported by a reticular framework of 
fibrous and elastic tissue. Fibers of elastic tissue, some of 
which are derived from the superficial abdominal fascia, run 
through the adipose layer in all directions. The round 
ligament may be traced into the mons on either side. Its 
integument, which is somewhat thicker than that of the 
2 



ESSENTIALS OF OBSTETRICS. 



abdomen, becomes invested at puberty with a growth ol 
short, crisp, curly hair ; it abounds in sebaceous and in 
sweat glands. The hairy growth extends an inch or more 



Fig, 




Vulva of the virgin. 1. Greater lip of right, side. 2. Fourchette. 3. Small 
lip. 4. Clitoris. 5. Urethral orifice. 6. Vestibule. 7. Orifice of the vagina. 8. 
Hymen. 9. Orifice of the vulvo-vaginal gland. 10. Anterior commissure of greater 
lips. 11. Anal orifice. 

above the level of the pubic bones. It is a peculiarity of 
the female that the hair of the pubic region is limited 
above by a sharply defined straight or convex line. 



ANATOMY OF FEMALE GEXFFAL ORGANS. 19 

The Labia Majora, or larger lips, are two prominent 
rounded folds springing from the mons veneris and ex- 
tending downward and backward on either side of the 
median line. At full development they lie in contact with 
each other in the young nullipara, except when the thighs 
are strongly abducted — vulva connivens. When shrunken 
from loss of fatty tissue in old age, or from the effects of 
childbirth, the labia minora protrude between them — vulva 
hi cms. They are thickest in front, and taper from before 
backward. The point of contact in front is spoken of as 
the anterior, and that behind as the posterior commissure 
of the vulva. There is, however, no true commissure in 
the sense of a connecting band at either point. 

The covering of the labia majora is skin. The outer 
surfaces, which are of a somewhat darker color than the 
surrounding integument, are supplied with hair which is 
most abundant anteriorly ; the inner surfaces resemble 
mucous membrane, but are sparsely covered with fine 
hairs. Both surfaces abound in sebaceous and in sweat- 
glands. Their internal structure consists chiefly of elastic 
and adipose tissue, and includes a rich venous plexus. 
Immediately beneath the skin is a layer of smooth mus- 
cular fibers analogous to those of the dartos in the male. 
Within this is the pudendal sac. It is made up of elastic 
fibers, and is attached by its neck to the external inguinal 
ring. Its fundus reaches nearly to the posterior vulvar 
commissure. Its cervix contains elastic and adipose tis- 
sue. The remains of the canal of Nuck may sometimes 
be traced into the pudendal sac. Each round ligament 
of the uterus terminates in the corresponding labium. 
The labia majora are the analogue of the scrotum in 
the male. 



20 ESSENTIALS OF OBSTETRICS. 

The Labia Minora, or Nymphae, the smaller lips, are 
two thin folds of delicate skin lying between the labia 
majora. They are widest toward their anterior extrem- 
ities, narrowing gradually from before backward. When 
at rest their inner surfaces are in contact. The outer sur- 
faces merge into the labia majora, the inner are continuous 
with the vestibule. Anteriorly each subdivides into two 
subsidiary folds. The superior folds join in front of the 
clitoris to form the prepuce, the inferior unite and are 
attached to the under surfaces of the glans to form the frse- 
num of the clitoris. Posteriorly they are united by the 
fourchette. 

In Bush women and in many Hottentots the smaller 
labia are hypertrophied, reaching half-way to the knees ; 
this overgrown structure is known as the Hottentot apron. 

In the virgin the nymphaB present the appearance of 
mucous membrane ; after long exposure from gaping of the 
vulva they look like skin. They are destitute of hairs and 
of sweat-glands. Sebaceous glands are found on both sur- 
faces. In general the histological characters of the outer 
surfaces are those of skin, not of mucous membrane. The 
minute anatomy of the inner surfaces lies between that of 
skin and mucous membrane. 

The internal structure of the nymphse includes some 
bundles of unstriped muscular fiber and a superficial capil- 
lary venous plexus, but no fat. 

The labia minora are richly supplied with nerve fibers. 

The Fourchette, or Frenulum Vulvae, is a transverse 
fold of skin immediately in front of the posterior vulvar 
commissure. It is scarcely apparent, except when put 
upon the stretch by separating the labia. It then ap- 
pears as a tense transverse fold between the posterior com- 



ANATOMY OF FEMALE GENITAL ORGANS. 21 

missure and the hymen. In the nulliparous woman its 
distance from the anal orifice is 3 cm., 1^ inch ; from the 
base of the hymen nearly 1 cm., I inch. 

The Fossa Navicularis is a boat-shaped space which 
appears between the hymen and the fourchette when the 
labia are separated. 

The Rima Pudendi is the median cleft between the labia 
of the right and the left sides. 

The Clitoris is situated in the median line below the 
anterior vulvar commissure. It is a very small cylin- 
drical body, and is slightly curved with its convexity out- 
ward. It has two corpora cavernosa and a glans analogous 
to those of the penis, but has no corpus spongiosum, and 
is imperforate. Continuous with the corpora cavernosa 
are the crura by which the clitoris is attached to the ischio- 
pubic rami. The body is attached to the pubic bones by 
the suspensory ligament. It is concealed behind the skin 
and is enclosed in a firm fibrous sheath. Its internal 
structure is made up chiefly of erectile tissue. The only 
visible portion of the organ is the glans, and this lies partly 
concealed in the preputial fold formed by the anterior lay- 
ers of the nympha? as has already been stated. Dur- 
ing erection the glans has a thickness of about 5 mm. 
The entire length of the clitoris is about one inch. Its 
mucous membrane is richly supplied with nerve papilla?. 

Arteries and Vein. — It has two arteries, the dorsal and 
the profunda, and a dorsal vein. The vascular supply is 
from the pudic artery. The dorsal vein empties into the 
vesical plexus and communicates freely with all the sur- 
rounding venous plexuses. 

The nerve-supply is derived from the internal pudic and 
from the hypogastric plexus of the sympathetic, and is four 



22 



ESSENTIALS OF OBSTETRICS. 



or live times more abundant than that of the penis. The cli- 
toris is the chief seat of voluptuous sensation in the female. 

Glands. — A few sebaceous follicles are to be found on 
the glans. 

The Vestibule. — This is the triangular surface bounded 
laterally by the labia minora and below by the margin of 




The bulbi vestibuli. (After Kobalt. ) 



the vaginal orifice. Its covering is mucous membrane. 
At its apex is the glans clitoridis. Immediately above 
the middle of its base is the meatus urethral This 
appears as a small tubercle or prominence with a me- 
dian cleft. The meatus lies 2 cm., J inch, below the 
glans clitoridis, and 2.5 cm., 1 inch, above the fourchette, 



ANATOMY OF FEMALE GENITAL ORGANS. 23 

in the nullipara. An intricate plexus of veins immedi- 
ately underlies the mucous membrane. This is the pars 
intermedia, so called from the fact that it connects the op- 
posite vestibular bulbs with each other and with the veins 
of the clitoris. 

The bulbi vestibuli are two leech-shaped masses of veins 
about 3.5 cm. in length, and are situated one on either 
side of the mesial line behind the labia, opposite the vaginal 
orifice and the base of the vestibule. In extent they reach 
from the level of the posterior margin of the vaginal orifice 
nearly to the clitoris. They lie between the bulbo- 
cavernosus muscle and the vaginal wall, immediately in 
front of the triangular ligament. They communicate freely 
with the veins of the labia, the vagina, the perineum, the 
glans clitoridis, and with other neighboring venous plex- 
uses. Each is enclosed in a fibrous sheath. Their internal 
structure comprises, in addition to venous plexuses and 
connective tissue, some smooth muscular fibers. The 
bulbs correspond to the bulbs of the urethra in the male. 

The Vulvo-vaginal Glands, (Hands of Bartholin or Du- 
verney. — These are the analogues of Cowper's glands in 
the male. They are two reddish-yellow bodies varying 
in size from a pea to an almond, lying one on each side 
of the posterior portion of the vaginal orifice, between the 
layers of the triangular ligament, sometimes anteriorly to 
both. They are partly covered by the lower extremities 
of the bulbi vestibuli. Their ducts, about 1.3 cm., J inch, 
in length, run along the inner aspects of the bulbi vesti- 
buli, opening just without the base of the hymen at the 
sides of the vaginal orifice. The secretion, which is a 
yellowish tenacious mucus, is poured out freely under 
sexual excitement and during labor. 



24 ESSENTIALS OF OBSTETRICS. 

The Hymen. — The hymen usually appears as a septum, 
partially occluding the vaginal orifice when the labia are 
drawn apart. When at rest it protrudes as a loose fold in 
the vulvar fissure. According to Budin, it is a thinned-out 
fold of the vaginal wall. Its most common form is that of 
a crescent, situated at the posterior margin of the introitus, 
with its concavity looking forward. It may, however, be 
annular, or may occupy the entire vaginal orifice, being either 
imperforate or cribriform — perforated with holes — or may 
have a single central opening with a fimbriated edge. Its 
histological characters are similar to those of the vaginal 
wall, yet it has but few muscular fibers. It is usually torn 
at the first sexual approaches. An untorn hymen is not, 
however, an infallible mark of virginity, nor is a torn 
one necessarily evidence that sexual intercourse has been 
practised. 

The Carunculae Myrtiformes. — The carunculse myrti- 
formes are the remnants of the hymen torn in labor by the 
passage of the child. They appear as minute fleshy tuber- 
cles, three or four in number, skirting the vaginal orifice or 
at least its posterior margin. 

Vessels, Lymphatics, and Nerves of the Pudendum. 

Arteries. — The arterial supply of the pudendum is de- 
rived from the superficial perineal branches of the internal 
pudic and from the external pudic artery. 

Veins. — The veins accompany the arteries. They form 
large plexuses and empty into the internal pudic and the 
inferior branch of the small sciatic. Varicosities are 
common during pregnancy. The venous plexuses of the 
labia become turgid during sexual excitement. 

Lymphatics. — The lymphatics go matnly to the super- 



ANATOMY OF FEMALE GENITAL ORGANS. 25 

fieial inguinal glands, which in turn communicate with 
the internal or with the external inguinal glands. 

Nerves. — The nerve supply, which is abundant, is from 
the superficial perineal nerve, which is given off from the 
pudic, the inferior pudendal nerve, which comes from the 
small sciatic, and from the inferior hypogastric plexus of 
the sympathetic. 

The Vagina. 

The vagina is that part of the genital tract between the 
uterus and the pudendum. Its direction is nearly parallel 
with the plane of the pelvic brim. It terminates below in 
the hymen or its remnants ; the upper part of the tube, 
which surrounds the cervix, is the roof or fornix of the 
vagina. The part of the upper extremity behind the cer- 
vix is the posterior, that in front the anterior fornix ; the 
lateral portions of the vaginal roof are spoken of as the 
lateral fornices. The posterior is deeper than the anterior 
fornix, owing to the higher attachment of the posterior 
vaginal wall to the cervix. 

Relations. — As already stated, its upper extremity is 
attached to the uterine cervix a little below the middle of 
its length, the lower portion of the cervix projecting into 
the vagina nearly at a right angle. The posterior wall 
for about one-fourth of its length is in relation at the vag- 
inal roof with the retro-uterine fold of peritoneum, the 
cul-de-sac of Douglas. Its lower end is united with the so- 
called perineal body ; at its middle portion, over about half 
its length, it is connected with the rectum by a loose connec- 
tive tissue. The upper part of the anterior wall is loosely 
attached to the bladder ; the lower half is intimately 
connected with the urethra, the latter being incorpo- 
rated in it. 



26 ESSENTIALS OF OBSTETRICS. 

Laterally the fornices are in relation with the bases of 
the broad ligaments ; below the fornices the vagina is at- 
tached on either side to the levator ani fascia. 

The recto-vaginal septum. — The united portions of the 
rectal and the posterior vaginal walls form the recto-vag- 
inal septum. 

The vesico-vaginal septum is formed by the union of the 
posterior wall of the bladder with the anterior vaginal wall. 

The urethro-vaginal septum is the partition between the 
urethra and the vagina. 

The Shape of the vagina when distended is approxi- 
mately that of a truncated cone with its larger end up. 
When at rest it is a collapsed tube, the anterior lying in 
contact with the posterior wall. Its cross-section in the 
adult presents the shape of an H, the limbs of which have 
a slight inward convexity. Its orifice, the introltus vagince, 
is nearly circular. The vaginal axis is approximately a 
straight line. 

The Size of the vagina is larger in women who have 
practised sexual intercourse than in virgins, and is much 
increased in child-bearing women. 

The length of the anterior wall in the virgin is 6.3 cm., 
2 J inches, that of the posterior wall 9 cm., 3| inches, or 
a little more. The walls, however, are extremely distensi- 
ble, and in parous women they become permanently en- 
larged and relaxed, sometimes attaining the length of 10 to 
12 cm., 4 to 4 J inches. The width of the canal at the widest 
part is about 4 cm., If inch, in the virgin ; in women who 
have borne children it is frequently 7 cm., 2 j inches. 

Structure. — The vagina has three coats : the external 
or fibrous coat ; the middle or muscular coat ; the inter- 
nal coat or mucous membrane. 



ANATOMY OF FEMALE GENITAL ORGANS. 27 

1. The fibrous coat is a prolongation of the recto- vesical 
fascia. 

2. The muscular coat consists of an inner circular and 
au outer longitudinal layer of unstriped muscular fibers. 
It is thickest near the vaginal orifice, thinnest in the 
upper part of the vagina. A band of voluntary muscular 
fibers, the bulbo-cavernosus muscle, encircles the vaginal 
orifice. 

3. The mucous coat is of a light pink color. It pre- 
sents two median ridges, one on the anterior and one on 
the posterior wall. Transverse ridges, cristce, run outward 
on either side from the longitudinal ones. The median 
columns with the transverse crista? are known as the 
cohimnce vagince. These structures are more marked on 
the anterior than on the posterior wall, and on both are 
most conspicuously developed near the vaginal orifice. 
They are rarely found at all above the lower two-thirds 
of the tube. They are more or less completely effaced by 
child-bearing and by catarrhal inflammation of the vagina. 
The mucous membrane of the lower portion of the vagina 
lies in loose folds when the canal is closed. Its surface 
is studded with papilla?. The epithelium is of the 
squamous variety. 

The arterial supply of the vagina is chiefly from the 
vaginal artery. The upper extremity of the tube receives 
branches from the uterine and the lower from the pudendal 
artery. These vessels anastomose with one another and 
with the vesical and rectal arteries. They all spring 
from the anterior division of the internal iliac. 

The veins correspond, but they first form plexuses en- 
tirely around the canal, one in the external coat and one 
in the submucous layer of connective tissue. They com- 



28 ESSENTIALS OF OBSTETRICS. 

municate with the hemorrhoidal, vesical, pudendal and 
pampiniform plexuses. None of these veins has valves. 

The Lymphatics. — The lymphatics of the lower fourth 
of the vagina join with those of the pudendum, terminating 
in the inguinal glands. Those from the remaining portion 
of the vagina unite with those from the cervix uteri and 
empty into the internal iliac glands. 

The nerves are derived from the fourth sacral and the 
pudic of the spinal system, and from the lower hypogas- 
tric plexus of the sympathetic. 

Glands. — The existence of true secreting glands, mucous 
glands, is by most anatomists denied. The vaginal secre- 
tion has an acid reaction, due to the presence of an acid- 
producing bacillus. 

The Urethra. — Intimately connected with the lower 
portion of the anterior vaginal wall is the urethra. Though 
not a generative organ, it is of obstetric interest, and is 
therefore described. 

Situation. — From the midpoint of the base of the 
vestibule the urethra passes backward beneath the pubic 
arch to the bladder. In the lower three-fourths of its 
length it is embedded in the anterior vaginal wall. It is 
supported by the pubo-vesical ligament, and it pierces the 
layers of the triangular ligament in the same manner as 
does this canal in the male. The portion of the canal be- 
tween the layers of the triangular ligament is encircled 
by the compressor ure three muscle. The general direction 
of the canal is nearly parallel with the pelvic brim. 

Shape. — Its shape is straight or very slightly curved, 
with its convexity downward and backward. When at 
rest its mucous membrane lies in longitudinal folds which 
are especially marked at the upper extremity. Its meatus 



ANATOMY OF FEMALE GENITAL ORGANS. 29 

is a vertical slit ; its vesical end is not funnel-shaped, as 
sometimes described ; the canal terminates abruptly in the 
bladder. 

Size. — The length of the urethra is about 4 cm., If 
inch, its average diameter is 6 mm., \ inch. It is largest 
at the vesical end, smallest at the meatus, and is very 
distensible. 

Structure. — It has two muscular coats, an outer cir- 
cular and an inner longitudinal layer and a mucous mem- 
brane. 

The epithelium of the urethral mucosa in the lower 
portion of the tract is of the squamous type ; toward the 
upper extremity it is of the transitional form, like that of 
the vesical mucous membrane. 

The vascular and the nervous supply are the same as 
those of the vestibule. There is a plexus of large veins 
around the canal, and another plexus between the two 
muscular coats. 

Glands. — Numerous lacunar and racemose glands are to 
be found on the surface of the mucous membrane. There 
are two tubular glands, known as Skene's glands, three- 
fourths of an inch in length, in the wall of the urethra 
near its floor, one on either side of the median line. Their 
orifices lie just within the meatus urethra?. 

Internal Genitals. 

These include the uterus, the Fallopian tubes and the 
ovaries. 

The Uterus. Situation. — In the erect position of the 
woman the uterus is situated in the cavity of the pelvis, 
between the bladder and the rectum, a little nearer to the 
sacrum than to the pubic bones. When the bladder and 



30 



ESSENTIALS OF OBSTETRICS. 



rectum are empty its upper border is nearly in the plane of 
the pelvic brim, its lower border just above the level of a 



Fig. 3. 




Sagittal section of the pelvis, showing relations of generative organs. 1. Body 
of the uterus. 2. Cavity. 3. Neck. 4. Cavity of the neck. 5. Intra-vaginal part 
of the neck. 6. Vagina. 7. Vaginal orifice. 8. Bladder. 9. Urethra. 10. Vesico- 
vaginal wall. 11. Rectum. 12. Bectal cavity. 13. Anus. 14. Recto-vaginal wall. 
15. Perineum. 16. Vesico-uterine cul-de-sac. 17. Utero-rectal cul-de-sac. 18. 
Pubic symphysis. 19. Small lip. 20. Great lip. 



ANATOMY OF FEMALE GENITAL ORGANS. 31 

line drawn from the lower end of the symphysis pubis to 
the tip of the sacrum, or in the plane of the ischial spines 
and posterior to a central position. The average direction 
of its long axis is nearly perpendicular to the plane of the 
pelvic brim. Its position, however, is variable within 
normal limits. A full bladder pushes it bodily back 
toward the sacrum and tilts the fundus backward. A dis- 





section of the nulliparous uterus, Section of parous uterus, showing 

showing shape of corporeal and cervi- shape of corporeal and cervical cavities, 
eal cavities, etc. etc. 

tended rectum displaces it forward. The upper portion of 
the uterus is in relation with the small intestines. The lat- 
ter sink into the upper part of the utero-sacral space and 
sometimes into the utero-vesical pouch. Posteriorly the 
uterus is separated from the rectum by a fold of perito- 
neum, which dips down into the pelvic cavity to the dis- 
tance of an inch or more below the cervico- vaginal junction. 
This retro-uterine pouch of peritoneum will be described 



32 ESSENTIALS OF OBSTETRICS. 

more fully later. Anteriorly the peritoneum covers about 
two-thirds the length of the uterus. That portion of the 
lower third of the uterus between the vagina and the 
peritoneum is attached to the bladder by loose connec- 
tive tissue. The lower uterine extremity projects into the 
upper end of the vagina to the extent of nearly 1.3 cm., 
J inch. The axis of the uterus forms approximately a 
right angle with that of the vagina when the former organ 
is in its usual normal position. Laterally the uterus is in 
relation with the broad ligaments, presently to be de- 
scribed. 

Shape. — The uterus is a hollow muscular body. Its 
shape is pyriform with its larger end uppermost. It is 
slightly flattened from before backward, its posterior and 
its upper surfaces are convex, its anterior aspect nearly 
flat. Its long axis is straight or slightly curved, with its 
conca v ity for wa rd . 

Size, (a) Nulliparous uterus. — The average measure- 
ments of the nulliparous uterus are 2.5 cm., 1 inch, nearly, 
in thickness antero-posteriorly, 3.8 cm., 1 J inch, in width 
at the level of the Fallopian tubes, and 6.3 cm., 2J inches, 
in length. 

(6) The parous uterus is approximately 2.5 cm., 1 inch, 
thick, 5 cm., 2 inches, wide, and 7.5 cm., 3 inches, long. 
The transverse thickness of the lower end of the uterus, 
the cervix, is 3.1 cm., 1J inch. The organ undergoes, 
marked atrophy after the menopause. 

Weight. — The nulliparous organ weighs about 28 
grams, 1 ounce ; in the parous woman the weight is 43 
grams, 1J ounce. 

Regional Divisions. — The uterus presents two principal 
divisions, the body and the cervix. 



ANATOMY OF FEMALE GENITAL ORGANS. 33 

The body is approximately the upper half of the uterus 
in the nulliparous, the upper two-thirds in the parous 
woman. 

The isthmus is the slight constriction at the junction of 
the body and the cervix. 

The fundus is that part of the body above the level of 
the Fallopian tubes. 

Divisions of the Cervix. — («) The infra-vaginal portion, 
or portio vaginalis, is that part of the cervix below the 
vaginal roof. Its average length in the parous woman is 
1 cm., a little less than J inch. 

(6) The supra-vaginal portion is that part between the 
portio vaginalis and the isthmus. Its length in the 
woman who has borne children is 1.5 cm., a little more 
than J inch. 

Uterine Cavity. — (a) The cavity of the body is some- 
what triangular in shape in the nullipara, its anterior and 
posterior walls lying practically in contact. It has three 
openings, one communicating with the cervical canal and 
one with each of the Fallopian tubes. 

(b) The cavity of the cervix is slightly flattened from 
before backward, and is laterally elliptical, thus having an 
irregular fusiform shape. 

The os internum is the upper orifice of the cervical 
canal, and is about 2.5 mm., -jL- inch, in diameter. 

The os externum, or os tincse, is the lower orifice, a lit- 
tle larger than the os internum. 

Structure. — The mucous membrane of the body of the 
uterus is about 1 mm., J§ inch, thick at the fundus and 
more than twice that thickness at the center of the body. 
No folds are to be observed in the mucosa of the body of 
the uterus except, perhaps, at the mouths of the Fallopian 
3 



34 ESSENTIALS OF OBSTETRICS. 

tubes. Its epithelium is of the ciliated columnar variety, 
the cilia, as stated by most anatomists, propelling toward 
the tubes. According to recent observations of Hofmeier, 1 
the ciliary movement is toward the external os. The 
mucosa of the body is firmly attached to the muscular 
structures. It abounds in tubular glands, many of which 
are bifurcated — the utricular glands. These are slightly 
tortuous, and, with few exceptions, extend to the muscu- 
laris ; some of them penetrate it. Generally their direc- 
tion is oblique to the mucous surface. They are lined 
with ciliated epithelium. Their secretion is alkaline. 
Dr. A. W. Johnstone ascribes to the corporeal endome- 
trium a glandular character comparable to that of the 
lymph-tissues in the walls of the alimentary canal and of 
other adenoid structures. 

The mucous membrane of the cervix is thicker, firmer, 
and paler than that of the body, and it is united to the 
muscularis by a distinct submucous layer of loose connec- 
tive tissue. On the anterior and on the posterior wall it 
presents a pinnate arrangement of ridges known as the 
arbor vitce or palmce plicatce. This consists of a median 
longitudinal ridge from which well-marked lateral processes 
run outward and upward. Upon and between the ridges 
of the arbor vitse are numerous racemose glands which are 
histologically mere inversions of the mucous membrane. 
In the upper two-thirds of the canal the epithelium on 
the crests of the transverse ridges of the palmge plicatse is 
ciliated. Elsewhere on the free surface it is goblet-shaped, 
without cilia. 

The gland-cells are cuboidal and non-ciliated. The epi- 
thelium of the lower third of the cervical canal and of the 
1 Centralb. f. Gyn., 1893, No. 33. 



ANATOMY OF FEMALE GENITAL ORGANS. 35 

entire external surface of the portio vaginalis is squamous, 
like that of the vagina. The secretion of the cervical 
glands is a clear tenacious mucus having an alkaline re- 
action. 

The muscularis constitutes the greater part of the thick- 
ness of the uterine walls. Its fiber is of the unstriped 
variety. The muscular wall is usually described as con- 
sisting of three layers ; but this division into strata cannot 
be made out except during gestation, and even then the 
layers are not distinctly separable. 

The outer layer, which is very thin, consists chiefly of 
longitudinal fibers which are continuous with the muscular 
layers of the Fallopian tubes, the ovarian, round, and 
uterosacral ligaments. 

The middle layer comprises the bulk of the uterine 
muscle and is a meshwork of interlacing longitudinal and 
circular bundles. 

The inner layer, which is made up of circular bundles, 
is extremely thin. It surrounds the orifice of the Fal- 
lopian tubes and forms a sphincter at the os internum. 

The cervix consists mainly of connective tissue. A 
well-marked band of circular fibers exists in the cervix 
at the vaginal junction. 

The Peritoneal Coat. — The uterus is partially enveloped 
in a transverse fold of the pelvic peritoneum. The latter 
structure invests the upper portion of the uterus, extend- 
ing over the entire length of the organ posteriorly and 
to the isthmus 'anteriorly. 

The Nulliparous and the Parous Uterus. — In the nullip- 
arous uterus the corporeal cavity is triangular, the fundus 
nearly flat, the cervix somewhat conical, and the os ex- 
ternum a mere dimple. In the parous uterus the cavity 



36 ESSENTIALS OF OBSTETRICS. 

is oval, the fundus dome-shaped, the cervix cylindrical, 
and the os externum a transverse slit, with the lips more 
or less fissured. The differences in weight and in size 
have already been stated. 

Position of the Uterus. — In the upright posture of the 
woman the average normal position of the uterus is such 
that the body lies nearly in a horizontal plane. 

Ligaments of the Uterus, (a) The broad ligaments. — 
The pelvic peritoneum dips down posteriorly into the lesser 
pelvis, is reflected over one inch or more of the upper 
part of the posterior vaginal wall, covers the posterior 
surface of the uterus, and passing over the fundus invests 
the anterior uterine surface to the isthmus ; thence it is 
again reflected upward and over the bladder. The uterus 
thus lies between the layers of a transverse fold of peri- 
toneum, the lateral portions of which, stretching from the 
uterus to the sides of the pelvis in front of the sacro-iliac 
joints, form the broad ligaments. The two layers of each 
broad ligament are nearly in apposition, except at their 
junction with the pelvic floor and with the pelvic walls. 
The Fallopian tube is enveloped in a subsidiary fold of 
peritoneum at the upper margin of the broad ligament. 
The round ligament directly underlies the anterior layer. 
The ovarian ligament runs between the two layers. 
There are also included between the two layers important 
blood vessels, lymphatics, nerves, smooth muscular fibers 
and connective tissue. 

The infandibido-pelvic, or ovario-peluie, ligament is that 
part of the superior border of the broad ligament on each 
side, extending from the Fallopian tube to the pelvic wall. 

(b) The utero-saeral folds are two semilunar folds of 
peritoneum enclosing unstriped muscular fibers and connec- 



< 




3 

CD 

H 



CD 


a 
a 



T3 
C 
S3 







CD 






ANATOMY OF FEMALE GENITAL ORGANS. 37 

live tissue, and passing one on each side of the rectum from 
the lower portion of the sides of the uterus to the second 
bone of the sacrum. In the nulliparous woman they spring 
from the uterus at the level of the os internum ; in the 
parous, from points somewhat above the os internum. 
These folds are also known as the folds of Douglas, and 
the space between them as Douglas's pouch or cul-de-sac. 
Luschka terms these ligaments the retractors of the uterus. 

(c) The utero-vesical folds are two folds of peritoneum, 
one on either side of the median line, which extend from 
the uterus to the bladder, forming the lateral borders of 
the utero-vesical space. They contain a few muscular fibers. 

(d) The round ligaments are two slender, flattened mus- 
culo-fibrous cords which spring from the angles of the 
uterus in front of the Fallopian tubes, and pass forward 
through the inguinal canals to blend with the structures at 
and immediately below the external ring. They contain 
unstriped muscular fibers. Their length is 10 to 12.5 cm., 4 
to 5 inches. A small artery and a vein pass through each. 

The Arteries. — The arteries of the uterus are the two 
uterine, the two ovarian and the two funicular arteries, or 
arteries of the round ligaments. The uterine artery is a 
branch of the internal iliac, the ovarian springs from the 
aorta. They pass to the uterus between the folds of the 
broad ligament on either side. The uterine artery reaches 
the uterus just above the vaginal junction, the ovarian at 
the level of the cornua. The former runs up along the lat- 
eral border of the uterus to communicate with the ovarian. 

The uterine arteries are remarkable for their free anasto- 
moses and their tortuous course. Arterial tufts are given 
off' at the lateral borders of the organ, whose branches 
form spirals within the uterine walls. They end in a mesh- 



38 ESSENTIALS OF OBSTETRICS. 

work of capillaries about the utricular glauds. Other 
branches of the uterine arteries anastomose with those 
from the opposite side encircling the uterus. The circu- 
lar artery surrounds the cervix at the isthmus, uniting the 
uterine arteries of the opposite sides with each other. 

The artery of the round ligament, which is a very small 
one, is a branch of the vesical given oif at the internal 
abdominal ring. It communicates at the cornua with the 
ovarian and the uterine artery. 

The Veins. — The uterine plexus of veins lies immedi- 
ately beneath the peritoneal coat of the uterus and extends 
between the folds of the broad ligament. It communi- 
cates with large sinuses in the middle muscular coat which 
are encircled by muscular bundles. The uterine veins 
also anastomose with the vaginal and the vesical plexuses. 
Their outlet is the hypogastric vein and the pampiniform 
plexus. 

The Lymphatics. — These are very numerous in the body 
of the uterus, and they communicate with the lymph-spaces 
of the mucous membrane and the muscular coat. They 
form an intricate network immediately beneath the perito- 
neal coat of the uterus, and communicate with those of the 
Fallopian tubes. The uteriue lymphatics are fully devel- 
oped only during pregnancy. The lymphatics of the 
body of the uterus with those of the Fallopian tubes and 
the ovaries empty into the lumbar glands. A group 
which follows the course of the round ligament ends in 
the inguinal glands. The cervical lymphatics unite with 
those from the upper part of the vagina and empty into 
the internal iliac glands. 

The Nerves. — These are derived chiefly from the sympa- 
thetic system, from the inferior hypogastric and spermatic 



ANATOMY OF FEMALE GENITAL OEGAXS. 



39 



plexuses. The uterus also receives filaments from the 
second, third and fourth sacral nerves. The uterine nerves 
terminate in part in the nuclei of the muscle-cells. 

The Fallopian Tubes or Oviducts. — These are two 
narrow tubes, one running outward from each horn of the 
uterus and communicating with the uterine cavity. The 

Fig. 6. 




Fallopian tube and ovary. (Savage.) 

outer portion of each tube takes a tortuous course, partially 
surrounding the ovary. The length of the tube is from 
7.5 to 12.5 cm., 3 to 5 inches, the right a little longer 
than the left. 

Divisions. — (a) The isthmus is the portion of the 
tube next the uterus. As it runs outward it expands 
gradually from 2 mm., yV inch, to 4 mm., ^ inch, in 
diameter. 



40 ESSENTIALS OF OBSTETRICS. 

(b) The ampulla is the dilated portion of the tube next 
beyond the isthmus, about 1 cm., J inch, in diameter. 
The fimbriated extremity, pavilion or infundibulum, is the 
free trumpet-shaped end of the tube, the margin of which 
is fringed with four or five processes called fimbriae. Here 
the tube expands abruptly to about 2 cm., 3J inches, in 
diameter. 

The fimbria ovarica is a special fimbria, a little larger 
than the others, which is attached to the ovary. 

The ostium uterinum barely admits a bristle, 1 mm., ^g 
inch, in diameter. 

The ostium abdominale, at which the body of the tube 
opens into the pavilion, is of the size of a small goose- 
quill, 5 mm. in diameter. 

Structure. — Each tube comprises three layers contin- 
uous, respectively, with the corresponding layers of the 
uterus : 

1. The outer or peritoneal coat, continuous with the 
peritoneal fold of the broad ligament. That part of the 
broad ligament between the tube aud the ovary is termed 
the mesosalpinx. 

2. The middle or muscular coat, composed of an inner 
circular and two outer longitudinal layers of unstriped 
muscular fiber. The outermost layer, however, is limited 
to the uterine end of the tube. The muscular coat con- 
tains a rich plexus of blood vessels. 

3. The inner or mucous coat. Except in the intramural 
portion of the tube, the mucous membrane is disposed in 
longitudinal folds, which become extremely complex in 
the ampulla. There is no distinct submucous layer. It 
is lined with ciliated columnar epithelium and is very vas- 
cular. The motion of the cilia propels toward the uterus. 



ANATOMY OF FEMALE GENITAL ORGANS. 



41 



According to Bland Sutton, the mucous membrane of the 
tubes is provided with glands. This is denied by Reck- 
linghausen. 

The arteries of the Fallopian tubes are branches of the 
ovarian and the uterine arteries. 

The veins open into the pampiniform or ovarian plexus 
lying between the folds of the broad ligament below the tube. 



Fig. 7. 




The ovary and oviduct. (The latter opened longitudinally.) 1,1. Ovary. 2. 
Part of the uterus. 3. Ovarian ligament, 4, 4. Oviduct, its walls opened by a 
longitudinal incision to show the longitudinal folds of its liuiug membrane. 5, 5. 
Pavilion from internal surface. 6, 6. Fimbria attached to the ovary, or tubo-ova- 
riau ligament, 7,7. Longitudinal folds. 8. Internal end of the oviduct, 

The lymphatics unite with those from the body of the 
uterus, and from the ovary, and terminate in the lumbar 
glands. 

The nerves are derived from the uterine and ovarian 
plexuses. 

The Ovaries. — The ovaries, two in number correspond 
to the testes of the male. 

Situations. — These organs are situated one on each side 
of the uterus 2.5 cm., 1 inch, or more below the level 



42 ESSENTIALS OF OBSTETRICS. 

of the ilio-pectineal line, and the same distance from the 
uterus ; yet they have great mobility within normal lim- 
its. Each is set in the posterior fold of the broad liga- 
ment, and is connected with the corresponding horn of 
the uterus by the ovarian ligament. 

Shape. — The usual shape of the ovary is a flattened 
ovoid ; its free border is convex ; the anterior edge is nearly 
straight. This straight border is the hilum. The ovary 
is thinnest at the hilum, thickest at the convex border. 
The inner end is narrower, pointed, and merges into the 
ovarian ligament ; the outer is more obtuse and bulbous. 
The shape, however, is variable. 

Size. — The size is about 3.5 cm., If inch, in length by 
2 cm., | inch, in width and 1.2 cm., J inch, in thickness, 
but is variable. The average normal weight in the nul- 
lipara is about 6 grammes (85 grains). The size increases 
during menstruation. 

Structure. 1. External. — In early age the external 
surface is smooth, like an almond. Later in life, after 
puberty, it gradually becomes uneven, acquiring a wrinkled 
appearance, owing to cicatrices from rupture of Graafian 
follicles. In the young adult subject it has a velvety 
softness and a pinkish or grayish-pearly color. In old 
age it acquires a cartilaginous hardness and a paler color. 
The free surface of the ovary is covered with modified 
peritoneum. Its epithelium is columnar and non-ciliated 
— the germinal epithelium of Waldeyer. 

2. Internal. — The stroma is made up of connective tis- 
sue with some unstriped muscular and elastic fibers. 

The tunica albuginea is a dense layer of stroma imme- 
diately underlying the germinal epithelium of the ovarian 
surface. 



ANATOMY OF FEMALE GENITAL ORGANS. 43 

The zona parenchymatosa is the cortical portion of the 
ovary ; it has a grayish color. 

The medullary zone, or zona vasculosa, is the portion 
about the hilam ; it is of a reddish color. Here enter the 
blood vessels, nerves, and lymphatics. 

The Ovarian Ligament is a muscular band about 0.5 
mm., i inch, in width, which extends between the folds 




Section of ovary magnified to showGraafiau follicle and ovum. 1. Surface epi- 
thelium. 2. Tunica albuginea, 3, 3. Different parts of stroma. 4. Tunica fibrosa 
of follicle. 5. Tunica? propria. 6, 6. Tunica granulosa. 7. Liquor folliculi. 8. 
Vitelline membrane of ovum. 9. Vitellus. 10. Germinal vesicle. 11. Germinal spot. 

of the broad ligament from the inner end of the ovary to 
the horn of the uterus, joining it immediately behind and 
below the origin of the Fallopian tube. Its length is 
about 2.5 cm., 1 inch. It is made up of connective tissue 
and smooth muscular fibers, the latter being continuous 
with the outer muscular layers of the uterus. 



44 ESSENTIALS OF OBSTETRICS. 

The arterial supply of the ovary is from branches of the 
ovarian artery which enter at the hilum. (Fig. 6.) 

The veins issue from the hilum and empty into the 
pampiniform plexus. (Fig. 6.) 

The lymphatics, with those of the tube and body of the 
uterus, empty into the lumbar glands. 

The nerves are derived from the inferior hypogastric 
plexus and the sacral nerves. 

Graafian Follicles. — The Graafian follicles are the sacs 
in which the ova are developed. The follicles are devel- 
oped from the germ epithelium of the ovarian surface, and 
become imbedded in the stroma by the outgrowth of con- 
nective tissue. They are most numerous in the cortical 
layer. Each follicle contains generally but one ovum. 
The number of rudimentary Graafian follicles at birth is 
35,000 or more in each ovary. At any time during the 
child-bearing period ten or twenty Graafian follicles may 
be found in different stages of development upon the ova- 
rian surface. The size of a mature Graafian follicle is 
TFo *° tV mcn m diameter. 

Structure of a Graafian Follicle. — The constituent parts 
of a Graafian follicle are : (1) The theca folliculi ; (2) the 
tunica (membrana) granulosa, a multiple layer of poly- 
hedral epithelium ; (3) the discus proligerus, or germinal 
eminence, a heaped-up mass of cells of the membrana 
granulosa at one side, containing the ovum ; (4) the liquor 
folliculi, a clear, albuminous fluid — paralbumin. 

The Parovarium. — The parovarium consists of a series 
of 10 to 20 tubules running between folds of the broad 
ligament in a slightly downward direction from the ovary 
toward the ampulla of the Fallopian tube. It is the rem- 
nant of the Wolffian body. 



PLATE II. 




Meso-salpinx laid open, showing the Parovarium or 
Organ of Rosenmuller. (Savage.) 



T, Fallopian Tube ; F, fimbriated extremity of same ; O, ovary ; i, remnant of Wolffian 
duct ; 2, 2, remnants of the caecal tubes of the Wolffian bodies ; 3, ovarian ligament. 



CHAPTER II. 
PHYSIOLOGY OF PREGNANCY. 

PHYSIOLOGY OF THE OVUM. 

OVULATION. 

Ovulation is the process by which the ovum or egg is 
matured and discharged from the ovary. At what inter- 
vals ovulation occurs in the human subject, and in what re- 
lation to the menstrual epoch, are not yet fully determined. 
Generally it takes place at about the time of the cata- 
menia. Ovulation, however, may occur independently 
of menstruation, and menstruation without ovulation. 
Robinson believes that ovulation begins before birth and 
continues after the menopause. As a rule but a single fol- 
licle ruptures at each epoch. 

MENSTRUATION. 

Menstruation is a periodic congestion of the female gen- 
ital organs, attended with a bloody uterine discharge — the 
menses or catamenia. The endometrium undergoes partial 
exfoliation and subsequent renewal. Popular terms for 
menstruation are the monthly sickness, the courses, monthly 
turns. 

The constituents of the menstrual flow are blood and 
remains of the endometrium, together with uterine and 
vaginal secretions. The amount is from three to fourteen 
ounces ; the length of the catamenial period is from two 



46 ESSENTIALS OF OBSTETRICS. 

to seven days ; the average duration four days ; the inter- 
val between the menstrual epochs is generally twenty- 
eight days. Intervals of several days more or less than 
the usual length, however, are to be considered normal, if 
constant. The source of the bloody discharge is the body 
of the uterus and probably the Fallopian tubes. Men- 
struation is usually attended with some degree of malaise, 
sacral pain and pelvic tenesmus. 

Puberty is the period of sexual maturity, and is 
marked in the female by the onset of menstruation. 

The age of puberty is usually about the fifteenth or 
sixteenth year. It varies with race, climate and other in- 
fluences, occurring in exceptional instances as early as the 
tenth or as late as the twentieth year of age. It is earlier 
in warm than in cold climates, in the better than in the 
poorer classes, and in city than in country life. At this 
period the girl takes on the physical and mental charac- 
teristics of womanhood. 

The Menopause. — The menopause is the final cessa- 
tion of menstruation and the capacity for child-bearing. 
Climacteric and change of life are synonymous terms for 
menopause. In most women this period begins at the 
age of forty-six years. The change, however, is a grad- 
ual one, occupying three to five years. Variations of ten 
years or more on either side of this limit are possible. 
The anatomical changes which take place in the sexual 
organs are essentially the reverse of those which charac- 
terize the pubescent period. In extreme old age the 
uterus is reduced to its infantile dimensions and the tubes 
and ovaries are almost obliterated. As a rule the men- 
strual function continues latest in those in whom it be- 
gins earliest. In cold climates the fruitful period begins 



PHYSIOLOGY OF PREGNANCY. 47 

late and ends late, and in hot climates it begins early and 
ends early. At the onset of the menopause the catamenia 
recur at irregular intervals, and finally they cease alto- 
gether. The intervals may be shortened or prolonged. 
The flow may be scanty or profuse and prolonged. Head- 
ache, tinnitus aurium, vertigo, hot flashes, palpitation, 
dyspnoea, faintness, pruritus and neuralgias are common 
nervous disturbances at this period. 

Phenomena Attending the Rupture of a Graafian 
Follicle. — Loops of blood vessels are projected into the 
cavity of the follicle, and an increase of the fluid contents 
of the sac takes place from the increased vascularity. Ad- 
jacent portions of the ovary, and to a certain extent its 
entire structure, exhibit a similar increase in vascularity. 
The follicle is now apparent as a bright red spot on the 
surface of the ovary. 

The overlying ovarian structure undergoes absorption 
owing to increased pressure of the liquor folliculi. The dis- 
tending follicle finally ruptures and discharges its contents, 
an effusion of blood taking place into the follicle after 
rupture. 

The ovum is apparently floated into the pavilion of the 
tube by a stream of serum which is propelled by the cilia 
of the fimbria ovarica. Its propulsion through the Fal- 
lopian tube is accomplished partly by ciliary motion, and, 
in the narrower portion of the tube, partly, perhaps, by 
muscular action. Heil thinks other agencies are concerned 
in the migration of the ovum into the oviduct, and be- 
lieves, as was formerly assumed, that the pavilion of the 
tube grasps the ovisac. 1 Rarely it happens that the ovum 
migrates across the pelvic cavity and into the opposite 
Fallopian tube. 

^•Vrch. f. Gyn., 1894, B. XLIIL, H. 3. 



4S 



ESSENTIALS OF OBSTETRICS. 



The Ovum. — The ovum is primarily a nucleated cell 
developed from the germ epithelium which covers the 
surface of the ovary. Its diameter at maturity is j±-q 
inch. 

The constituent parts of the ovum are : 

The vitelline membrane; 

The vitellus or yolk, oleo-albumiuous matter, containing 
shining granules ; 

Fig. 9. 




Section of nearly mature ovum aud part of Graafian follicle, o. Membrana 
granulosa, b. Discus proligerus. c. Vitelline membrane. /. Vitellus. 



The germinal vesicle, which is the nucleus of the cell? 
Y^-q inch in diameter, situated to one side of the yolk near 
its surface ; 

The germinal spot, the cell nucleolus, a dark, granular 
spot, about 3~oVo inch in diameter, within the vesicle. 

The Female Pronucleus. — The germinal vesicle ap- 
proaches one pole of the ovum, and two rounded masses, 
the polar globules, are successively extruded from the sur- 



PHYSIOLOGY OF PREGNANCY. 



49 



face of the egg. The office of these bodies is unknown. 
The remaining portion of the germinal vesicle reappears 
in the center of the egg, and is now known as the female 
pronucleus. As will be seen presently, the fusion of the 
female with the male pronucleus is the essential fact in 
fecundation. 

The Corpus Luteum. — The corpus luteum is the body 
formed in the ovary by the changes which take place in 
the Graafian follicle after rupture. 

The corpus luteum of menstruation reaches its full devel- 

Fig. 10. 




Section of human ovary, showing corpus luteum. 



opment in from two to four weeks, and it becomes re- 
duced to a mere cicatrix in about two months. 

The corpus luteum of pregnancy grows for six or seven 
weeks, then it remains stationary to the end of the fourth 
month ; from that time it retrogrades slowly till term, 
and becomes a mere cicatrix by the end of a month after 
childbirth. The period of growth, however, and the ra- 
pidity of decline, are not in all cases the same. 



50 ESSENTIALS OF OBSTETRICS. 

CONCEPTION— IMPREGNATION. 

Impregnation, or conception, is the fructification of the 
ovum by union with the spermatozoon, the fecundating ele- 
ment of the male. Insemination is the act by which the 
seminal fluid is deposited in the female genital tract. 

The Seminal Fluid. — The seminal fluid is a glutinous, 
alkaline, albuminous fluid, of a whitish color, heavier than 
water, and is the combined product of the testicles, the 
prostate and Cowper's glands. The quantity ejaculated 
during an orgasm is from one to three drachms. Its 
chemical constituents are water, fats, proteids, calcium 
and sodium chlorides and phosphates. The proportion of 
mineral ingredients is about 3 per cent. Its microscopic 
elements are epithelium, leucocytes, spermatozoa, and crys- 
tals of calcium phosphate. 

The Spermatozoa. — The spermatozoa are bodies of 
microscopic size resembling tadpoles in shape. The parts 
of the spermatozoon are a flattened ovoid head (cell nu- 
cleus) and a long thread-like tail. The filiform tail main- 
tains a constant vibratile motion, the result of amoeboid 
movements of protoplasm, so long as the spermatozoon re- 
tains its fecundating power. The total length of a sper- 
matozoon is -g-i-Q to jI-q inch. 

Vitality of Spermatozoa. — Under favorable conditions 
the spermatozoa, as well as the ovum, live w r ithin the gen- 
ital passages of the female for a week or more. In the 
human species they have been found in active motion after 
eight days. Duhrssen found them alive in the Fallopian 
tube after three and a half weeks. 

They are destroyed by extremes of heat or cold. The 
seminal elements of man retain their motility, however, 



PHYSIOLOGY OF PREGNANCY. 51 

between the temperatures of 5° and 116° F. They are 
destructible by acids, by numerous other chemical agents 
and by desiccation. 

The Migration of Spermatozoa. — Under normal condi- 
tions the male fluid is ejaculated upon and about the cer- 
vix. Yet the spermatozoa may traverse the entire length 
of the female genital tract by their own powers of loco- 
motion, and impregnation may take place in exceptional 
cases without introception of the male organ. Loco- 
motion is accomplished by the lashing action of the tail. 
The rate of motion is about an inch in seven and one-half 
minutes. 

Place, Time and Mode of Impregnation. — Impregnation 
is by most authorities thought to take place in the outer 
portion of the Fallopian tube. The usual date of con- 
ception is probably within a week after the cessation of a 
menstrual period. As a rule, the ovum is fecundated by 
a single spermatozoon. The spermatozoon penetrates the 
egg, its tail is absorbed, and its head forms the male pro- 
nucleus. The male moves toward the female pronucleus 
and unites with it to form the vitelline or segmentation nu- 
cleus of the fecundated egg. The fructified egg is called 
the oosperm. 

DEVELOPMENT OF THE IMPREGNATED OVUM. 

The egg on leaving the ovary has a diameter of -j^ 
inch. At its escape from the ovary it is partially en- 
veloped in cells of the membrana granulosa. During its 
transit through the oviduct it receives an albuminous en- 
velope wmich supplies the first nutriment for its develop- 
ment. On its entrance into the uterus it lodges in the folds 
of the decidua. 



52 ESSENTIALS OF OBSTETRICS. 

Segmentation. — Immediately after the formation of 
the vitelline nucleus the yolk subdivides into two spheres. 
The process of cleavage begins in the nucleus and ex- 
tends throughout the vitelline mass. The two cells thus 
formed lie within the zona pellucida. By the continuance 
of the process of segmentation these cells divide into four 
and the four into eight, and so on until the entire yolk 
becomes a granulated mass. The latter has received the 
name of the muriform body. Cleavage taking place through 
the vitelline nucleus, its ultimate segments form the nuclei 
of the resulting cells. These cells are of two sizes. The 
smaller, which are the more transparent and are cubical 
in shape, are the epiblastic ; the larger which are polyg- 
onal in form, are the hypoblastic cells. Segmentation in 
the human subject probably does not occupy more than six 
days. By the time it is complete the ovum usually has 
reached the cavity of the uterus and has grown to a di- 
ameter of -gJ-g- to 2V inch. 

The Blastoderm. — The epiblastic cells unite to form a 
continuous layer which lines the zona pellucida. This is 
the epiblast or ectoderm. 

By the union of the hypoblastic cells is formed another 
layer, the hypoblast or endoderm. The epiblast and the 
hypoblast are in contact within the area which marks the 
site of the future embryo, elsewhere they are separated by 
fluid. Between these two a third layer, the mesoblast or 
mesoderm, is subsequently formed. This layer, however, 
is limited to that part of the oosperm at which the embryo 
is to be developed. The three layers together constitute 
the blastoderm. The oosperm, now dilated into a vesicle 
by accumulation of fluid in its cavity, is called the blasto- 
dermic vesicle. 



PHYSIOLOGY OF PREGNANCY. 53 

DEVELOPMENT OF THE EMBRYO. 

From the ectoderm are formed the epidermis, hair, 
nails, teeth and the glandular structures of the skin, the 
mammary glands, cerebro-spinal nervous system, the 
organs of special sense, and the chorion, amnion and 
placenta. 

From the mesoderm are developed bone, muscle, con- 
nective tissue, the heart and blood vessels, peritoneum, 
pleura?, pericardium, spleen and the genito-urinary organs. 

From the endoderm are formed the lungs, liver, stomach, 
oesophagus, pancreas, intestines, the epithelium of the di- 
gestive tract, the bladder, and the allantois. 

The area germinativa, or embryonic spot, appears upon 
the blastoderm as an opaque, oval spot, consisting of an 
aggregation of hypoblastic cells on the inner surface of 
the membrane. In the long axis of this area the embryo 
is developed. 

The area pettucida is a clear, oval space, which soon 
appears in the center of the area germinativa. 

The primitive trace is a longitudinal streak which appears 
in the median section of the area pellucida in consequence 
of a thickening of the blastodermic layers in this part. 

The medullary canal. Two longitudinal folds spring 
up, one on either side of the primitive trace, and by the 
end of the first month of intrauterine life they have arched 
over and united to form the medullary or cerebro-spinal 
canal. 

Somatopleure and Splancknopleure. — The mesoblast on 
either side of the median-axial line splits into two lamina?, 
the outer one of which unites with the epiblast to form 
the somatopleure or primitive body -wall, and the inner 



54 ESSENTIALS OF OBSTETRICS. 

one with the hypoblast to form the primitive splanchno- 
pleure or rudimentary digestive tract. The space between 
the somatopleure and the splanchnopleure is the primitive 
body-cavity. This is ultimately divided into pleural, 
pericardial and peritoneal cavities. 

THE FCETAL MEMBRANES. 
The Amnion. — This is the innermost of the foetal en- 
velopes. At about the time when the embryo begins to 
take shape folds of the somatopleure spring up around 
the edges of the embryo. (Figs. 11 and 12.) This mem- 

Fig. 11. 



a, a. Beginning development of amnion, z. Zona pellucida or vitelline membrane. 
s. Epiblast. m. Hypoblast, u. Umbilical vesicle. 

branous ridge grows until its edges meet over the back of 
the embryo. The surfaces brought into contact become 
fused together. (Fig. 13.) The pouch thus formed is 
the amnion. Within it is the embryo. It is gradually 
expanded by accumulation of its fluid contents, the liquor 
am nii. 

The outer layer of the folds, which is termed the false 
amnion, recedes to the vitelline membrane. 

The liquor amnii is an alkaline liquid having a specific 
gravity of 1002 to 1015. In the earlier months of preg- 



PH YSIOLOQ Y OF PREGNA NGY. 



55 



nancy it is clear and transparent ; in the later months it 
becomes turbid, owing to the presence of skin epithelium, 
lanugo and particles of vernix caseosa. At the time of 
labor it sometimes has a dark greenish-brown color, from 
the presence of meconium. In the first half of pregnancy 
it is contributed from a system of capillary blood vessels of 
the placenta immediately underlying the amnion. In the 
later months, according to some authorities, it consists 

Fig. 12. 




a, a. Development of amnion at a more advanced stage, p. Allantois. 



partly of foetal urine. Others deny that foetal urine is 
discharged into the liquor amnii except during labor. 

Its principal constituents in the last weeks of pregnancy 
are water, a trace of albumin, mucin, saline matter, creatin, 
creatinin, urea, epithelium. The normal quantity at term 
is from one to two pints. 

Uses. — During gestation it not only permits active 
foetal movements, but it protects both the uterus and the 
foetus by equal distribution of the intrauterine pressure. 
Swallowed by the foetus, and, in the early months of ges- 
tation, absorbed through the skin of the embryo, it sup- 
plies water to the foetal tissues. During parturition, so 



56 ESSENTIALS OF OBSTETRICS. 

long as the membranes are unbroken, it helps to dilate the 
cervix by hydrostatic pressure. 

The Allantois. — The allantois is a diverticulum devel- 
oped from the posterior part of the endoderm or the intes- 
tinal canal at about the time the amniotic folds are formed. 
It is projected to the outer envelope of the ovum, which 
now consists of the vitelline membrane and the false 




Amnion complete. Allantois in contact with external envelope of ovum. 



amnion joined in one. It spreads until, by the end of 
the third week, it lines the entire external envelope of 
the ovum as a flattened sac. (Figs. 12, 13 and 14.) 

Its office is to carry blood vessels from the embryo to 
that portion of the outer envelope at which the placenta 
is to be developed. The allantoic arteries are two in num- 
ber ; after the complete development of the umbilical cord 
they are called the umbilical arteries. 

The stem of the allantois ultimately dwindles to a mere 
cord, which is termed the umbilical communication : this is 
the rudimentary umbilical cord. 



PHYSIOLOGY OF PREGNANCY. 57 

The Chorion. — This structure consists mainly of a layer 
of connective tissue and one of pavement epithelium. The 
former becomes fibrous in the later months of pregnancy. 

In the second week of its development the ovum be- 
comes invested with villosities which spring from its outer 
covering, the vitelline membrane. This envelope, with 
its villi, is the primitive chorion. The permanent chorion 

Fig. 14. 




Allantoic folds united. 4. Umbilical vesicle. 7. Stem of allantois. 

is formed by fusion of the allantois with the vitelline mem- 
brane and the false amnion. This structure consists 
mainly of a layer of connective tissue and one of pave- 
ment epithelium. The former becomes fibrous in the later 
months of pregnancy. The space which persists for the 
time between the amnion and the chorion is filled with a 
gelatinous material. 

Union of the Foetal Envelopes. — The amniotic sac ex- 
pands until it reaches the chorion and blends with it about 
the end of the second month. At that time the coverings 



58 ESSENTIALS OF OBSTETRICS. 

of the ovum, from within outward, are the amnion, the 
chorion, the decidua reflexa, the decidua vera. Soon after 
the third month they become practically a single mem- 
brane. The ovum loosens its hold upon the uterus at term 
by the formation of a meshy layer in the decidua. 

Chorial Villi. — Shortly after the fixation of the ovum 
the surface of the chorion, as has already been stated, be- 

Fig. 15. 










r-. 



V 

Couipouud villus from ovum of three months. (^laguified 30 diameters.) 

comes covered throughout with transparent villi. The 
villi penetrate the decidua, and from it they derive nu- 
trient material for the sustenance of the growing ovum. 
At first they are single, but as the ovum develops they 
elongate and become compound. (Fig. 15.) The ex- 
ternal surface of the globular ovum is, at this period, 
everywhere " shaggy." (Fig. 14.) 

Blood Vessels of the Villi. — At first the villi are not vas- 



PHYSIOLOGY OF PREGNANCY. 59 

eular, but they soon receive blood vessels from the allan- 
tois. The capillaries of the chorial villus enter the stem 
of the villus, follow its subdivisions to the end of each 
rootlet, there forming loops, and return to empty into the 
venous trunks of the chorion. The chorial villi are com- 
parable, in structure and function, to those of the in- 
testines. 

Chorion Lseve. — Toward the end of the second month 
the chorion begins to grow bald over its entire surface, 
except the portion corresponding to the insertion of the 
foetal blood vessels. Thus by the end of the second 
month two-thirds of the surface of the chorion is smooth, 
the chorion Iceve. 

Chorion Frondosum. — Over the remaining third of the 
chorial surface the villosities grow more profusely than 
before to form a thick, spongy mass of villosities ; this 
part of the chorion is the chorion frondosum. The villi 
are destined to form the foetal portion of the placenta. 
In the placental part of the chorion the development of 
the vessels keeps pace with that of the villosities ; else- 
where the capillaries shrink with the atrophy of their villi. 

After full development of the placenta the non-pla- 
cental portion of the chorion, the chorion lseve, serves 
only for protection. 

The Deciduae. — With the fixation of the impregnated 
ovum upon the uterine mucous membrane, the latter 
structure undergoes important alterations. It becomes 
increased in vascularity and in thickness, and a fold of 
the mucosa grows up around the ovum, completely en- 
veloping it. This hypertrophied mucous membrane of 
the uterus is called the decidua. That part of the deci- 
dua which underlies the portion of the ovum at which the 



60 



ESSENTIALS OF OBSTETRICS. 



placenta is subsequently to be developed is the decidua 
serotina or placental decidua. The rest of the uterine 
mucous lining is the decidua vera or uterine decidua. (Fig. 
16.) The reflected portion which envelopes the ovum is 
termed the decidua reflexa or circumflexa, the ovular or 
epichorial decidua. (Figs. 17 and 18.) The space inter- 
vening between the reflexa and the vera is filled with thick, 
viscid mucus. The reflexa grows with the ovum and comes 
in contact with the vera during the fourth month, uniting 



Fig. 16. 



Fig. 17. 



Fig. 18. 




Decidua with ovum 
lodged in its folds. 



Beginning formation 
of reflexa. 



Reflexa completely envelop- 
ing the ovum. 



with it. The cavity of the uterus is from this time com- 
pletely filled by the ovum and its coverings. Except at 
the placental site, the decidua? undergo atrophy and are 
reduced to a single thin membrane by the close of the first 
trimester ; the decidua reflexa disappears entirely after the 
seventh month. 

The Placenta. — The placenta, or after-birth, when 
fully developed is a mass of spongy consistence and 
lenticular shape, measuring from 18 to 20 cm., 7 to 8 



PHYSIOLOGY OF PREGNANCY. 



61 



inches, in diameter and about 2.5 cm., 1 inch, in thick- 
ness at the insertion of the cord. Its outline is some- 
times round, most frequently oval. Its usual weight is 
454 grms., 1 pound. The size of the placenta, however, 
usually varies with that of the child. 

The foetal surface is a smooth, somewhat concave surface 

Fig. 19. 




Foetal surface of'placenta. 



of amniotic membrane. The insertion of the umbilical 
cord is most frequently central or nearly so ; sometimes 
it is eccentric or even marginal. The larger ramifications 
of the placental vessels are visible beneath the foetal mem- 
branes. (Fig. 19.) 

The maternal surface is brownish-red, slightly convex 



62 ESSENTIALS OF OBSTETRICS. 

and rough, presenting divisions into irregular lobes or 
cotyledons from 1 to 4 cm., J to 1J inches, in diameter, 
and sixteen to twenty in number. These lobes are sepa- 
rated by membranous septa which penetrate the substance 



Fig 




Maternal surface of placenta. 

of the placenta to the fcetal surface. The maternal sur- 
face is covered with the outer layer of the serotina. 

The placental seat is normally the upper segment of the 
uterus. It is found on the anterior or the posterior wall 
with nearly equal frequency. It may be situated, how- 



Oh 




CD 




<Z 








%, 




<D 








D 


^~~~ 




r 


T3 





CO 





cd 







J 


c 




0) 


u 





CD 


od 


in 


E 


< 



0) 



CO 

a 
s 

cd 

CO 



CO 



PHYSIOLOGY OF PREGNANCY. 63 

ever, on any portion of the walls of the body of the 
uterus. 

Development. — The formation of the placenta begins 
in the second month of pregnancy. Its limits are dis- 
tinctly defined by the end of the third ; its characteristic 
form and structure are complete by the end of the fourth 
month. The chorionic villi are projected into the inter- 
glandular portions of the endometrium and ramify to form 
dendritic tufts. The walls of the crypts into which the 
villi dip are lined with epithelium and are extremely vas- 
cular. The capillaries around the crypts become enlarged 
and inosculated till every loop of the foetal villi is sur- 
rounded by a meshwork of dilated maternal capillaries. 
The latter enlarge, obliterate the interspaces, and coalesce 
into lakes of blood. These blood-spaces are in free com- 
munication with the uterine sinuses. 

Structure. — The placenta is made up essentially of foetal 
and maternal blood vessels. The vascular foetal tufts, 
sixteen to twenty in number, are suspended, as it were, in 
lakes of maternal blood. The latter are fed by the curl- 
ing arteries of the uterus. The maternal blood returns 
from the spaces between the foetal tufts by the coronary 
vein at the margin of the placenta and by sinuses in the 
septa between the cotyledons. The foetal and maternal 
circulations have no direct communication with each other. 
(Plate III.) 

Function. — The placenta is at once the nutritive, the 
respiratory, and the excretory organ of the foetus. The 
interchange between the foetal and maternal circulation 
takes place by osmose through the walls of the foetal villi. 

The Umbilical Cord. — The umbilical cord is the pedi- 
cle which, during gestation, connects the foetus with the 



64 ESSENTIALS OF OBSTETRICS. 

placenta. It is developed from the stalk of the allantois. 
Its foetal insertion is at the umbilicus, the placental is 
generally nearly central. (Plate IV.) 

The usual length of the cord varies from 7 to 60 inches. 
Greater variations are exceptionally observed. The average 
length is 20 inches. Its diameter is about that of the 
little finger of the adult. The tensile strength, at term, 
is from five to twelve pounds. 

Structure. — The cord contains the remnants of the 
vitelline duct and the umbilical vesicle and the umbilical 
vessels imbedded in a jelly-like connective tissue, the jelly 
of Wharton. It is invested with a sheath derived from 
the primitive somatopleure. The covering, though re- 
sembling amnion, is not a process of that structure, as 
usually assumed. 

Blood Vessels. — Primarily it has two arteries and two 
veins ; subsequently one of the veins disappears. Excep- 
tionally there is but one artery. The walls of the arteries 
are but little thicker than those of the veins. The vessels 
of the cord are arranged in spirals, the vein appearing to 
be wound around the arteries. According to recent ob- 
servations nutritive capillaries, and also nerves and lym- 
phatics, are to be found in the cord. 

Rate of Development of the Embryo and Foetus. 

First Month. 1 — The ovum is of the size of a pigeon's 
egg ; its diameter is 2 cm., f inch. Chorionic villi are 
present over its entire surface. The length of the embryo 
is nearly 1 cm., J inch ; its weight about 1 gramme, 15.43 
grains. The first rudiments of foetal structure are discern- 
ible. The heart, kidneys, liver, extremities, and the eyes, 

1 Lunar month. 



PLATE IV. 




Evolution of the Placenta and of the Umbilical Cord. 
(From Sappey.) 



i, i. Embryo. 

2, 2, 2. Amnion. 

3, 3, 3. Cavity of Amnion. 

4, 4. Digestive Canal. 

5, 5. Pedicle of the Umbilical Vesicle. 

6, Umbilical Vesicle. 



7, 7. Allantoic! Vessels. 

8, Pedicle of the Allantois. 

9, 9, 9. Chorial Villi beginning to atrophy. 

10, 10. Villi in relation with the utero-placental 

decidua, which hypertrophy. 



PHYSIOLOGY OF PREGNANCY. 65 

the oral and anal orifices begin to be formed. The nose 
and month are one cavity. The heart begins to beat at 
the third week. The abdomen is not fully closed. The 
spinal canal closes. The members are indicated by papillae- 
Second Month. — The ovum is of the size of a hen's egg, 
6.5 cm., 2 J inches, in diameter ; the length of the embryo 
is about 2J cm., 1 inch. Rudimentary vertebrae ap- 
pear. The frontal unite with the superior maxillary 
processes. Centers of ossification are present in the in- 
ferior maxillary bone, the clavicle and the sides and 
bodies of the vertebrae. The visceral arches are closed, 
or nearly so. The eyes, nose, and ears begin to take 
form. The mouth and nose are separate cavities. Rudi- 
ments of hands and feet appear, but the fingers and toes 
are webbed. The umbilical vesicle has disappeared. The 
umbilical cord is about 2.5 cm., 1 inch, in length. Sexual 
organs are apparent. 

Third Month. — The ovum is of the size of a goose's 
egg ; its diameter is 4 to 9 cm., 1 J to 3 \ inches ; the aver- 
age length of the embryo is about 6.5 cm., 2J inches; 
its weight 30 grammes. The placenta is nearly complete ; 
the villi have atrophied over two-thirds of the chorion. 
The umbilical cord is 7 cm., 2| inches, in length, and its 
vessels begin to be twisted. The external parts of the 
embryo are distinctly formed. Ossific centers are appar- 
ent in most of the bones. The fingers are separated, also 
the toes. Rudimentary finger- and toe-nails are present. 
The cavities are wholly closed. Sex is determinable by 
the presence or absence of a uterus. Active foetal move- 
ments begin in the latter part of this month. 

Fourth Month. — The average length of the foetus is 
13 cm., 5 J inches; its average weight is about 56 
5 



PLATE V. 




The Mature Ovum. (After Runge.) 



A. Uterine Wall. 

B. Placenta. 

C. Umbilical Cord. 

D. Decidua. 



E. Chorion. 

F. Amnion. 

G. Fcetus. 

H. Amnial liquor. 



PHYSIOLOGY OF PREGNANCY. 67 

| inch less than at term ; the average weight is about 
2,721 grammes, 6 pounds; an.ossific nucleus first appears 
in the lower femoral epiphysis. Lanugo is disappearing 
from the body. 

Tenth Month. Signs of Maturity. — Measurements : 
length 45 to 50 cm., 18 to 20 inches; suboccipito-breg- 
matic circumference 33 cm., 13 inches; length of foot 8 
cm., 3| inches. The weight is 3,175 to 3,288 grammes, 
7 to 7J- pounds. The eyes are usually open. The face 
and body are plump. The child suckles and cries lustily. 
Lanugo is almost wholly absent from the body. Vernix 
caseosa, as a rule, is present only on the child's back and 
on the flexor surfaces of the limbs. The finger-nails 
overreach the finger-tips, the toe-nails extend to the end 
of the bed of the nail. The cartilages of the ear and of 
the nose have become firm. The cranial bones are hard, 
and the sutures and fontanelles small. Centers of ossifi- 
cation are well developed in the lower epiphyses of the 
femurs and in the astragalus ; they are beginning to ap- 
pear in the upper epiphysis of the tibia and in the cuboid 
bone. (Plate Y.) 

FCETAL CIRCULATION. 

The peculiarity of the foetal circulation arises chiefly 
from the fact that pulmonary respiration is in abeyance 
during intrauterine life, the respiratory blood-changes be- 
ing accomplished in the placenta. Only so much blood 
goes to the lungs as is needed for their nutrition. From 
the placenta the blood passes to the umbilical vein. A 
part goes directly to the ascending cava by the ductus 
venosus, and a part reaches it indirectly through the liver 
and the hepatic vein. Together with the blood from the 



ESSENTIALS OF OBSTETRICS. 



lower extremities it then goes to the right auricle, and 
thence is deflected through the foramen ovale into the left 
auricle by the Eustachian valve, whence it passes through 

Fig. 21. 




Internal Iliac Arteries. 

Diagram of the foetal circulation. (Flint.) 

the left ventricle and into the aorta. The larger part 
goes to the arms and the head. Returning by the de- 
scending cava to the right auricle it goes to the right ven- 



PHYSIOLOGY OF PREGNANCY. 



69 



tricle, a very small part passing to the lungs by the pul- 
monary artery, the larger part reaching the aorta through 
the ductus arteriosus ; a small portion of this mixed blood 
goes to the lower extremities, the greater part being re- 
turned again to the placenta by the hypogastric arteries. 



EFFECTS OF PREGNANCY ON THE MATERNAL 

ORGANISM. 
Changes in the Uterus. — Naturally the first effects of 
pregnancy are to be found in the uterus. The most nota- 

Fig. 22. 




of uterus at different periods of pregnancy. 



ble clinically are the alterations in the size, shape and 
structure of the uterus. 

Size. — The growth of the uterus begins immediately on 
fixation of the ovum, and is continuous with its growth. 



70 ESSENTIALS OF OBSTETRICS. 

In the first two months its development is chiefly in the 
lateral and antero-posterior directions. Subsequently the 
growth is nearly symmetrical. It is mainly due to hyper- 
trophy and to hyperplasia of its muscular fibers. In the 
later months the enlargement is in part by dilatation. 

The thickness of the uterine walls at term is between 
4 and 6 mm., J and J inch. The internal surface is ex- 
panded between conception and full term from 32 or 39 
square cm., 5 or 6 inches, to 2256 square cm., 350 square 
inches. The cubic capacity of the uterus is enlarged 
more than five hundred times, to 4000 cc. or more. 
The weight increases from 43 grammes, 1J ounces, its 
weight in the pregravid state, to 904 or 1133 grammes, 
2 to 2J pounds, at term. 

Dimensions of the Gravid Uterus. 



Stage of gestation. 


Total length. 




Width. 


12 weeks 


12.5 cm. (5 in.) 


10 


cm. 


(4 in.) 


16 Aveeks 


15 


< (6 ") 


12.5 


(< 


(5 ") 


20 weeks 


17.5 


' (7 " ) 


15 


" 


(6 <<) 


24 weeks 


21.5 


' (8* " ) 


16.5 


a 


m " ) 


28 weeks 


25 


< (10 ") 


17.5 


" 


(7 ") 


32 weeks 


29 


< (11J " ) 


20 


" 


(8 ") 


36 weeks 


33 


< (13 ») 


22.5 


" 


(9 ») 


40 weeks 


35.5 


< (14 " ) 


25 


" 


(10 ") 



Shape. — In the first three months the shape of the 
uterus is irregularly pyriform ; in the second, the body of 
the uterus is a flattened spheroid, its antero-posterior di- 
ameter being the smallest ; in the last it is generally egg- 
shaped, the fundal being the larger end. Yet the form of 
the uterus in the later months is not altogether constant. 

Structure. — The changes which take place in the mu- 
cosa have already been described. The muscular fibers 
grow 7 to 11 times in length, 2 to 5 times in thickness; 



PHYSIOLOGY OF PREGNANCY. 71 

there is also some hyperplasia of muscular tissue. At 
the internal os there is a preponderance of circular fibers 
in all the layers. The peritoneal coat develops in pro- 
portion to the increasing size of the uterus. 

The arteries increase in number, length and caliber. 
By the later months of pregnancy the ovarian arteries 
attain the size of goose-quills, and the uterine arteries are 
somewhat larger still. The size of the lateral branches, 
which connect the ovarian and the uterine arteries on 
each side exceeds that of the radial artery. The uterine 
venous plexus develops into a system of huge sinuses in 
the middle coat of the muscularis, and in the subpla- 
cental portion of the inner coat. Some of these vessels 
attain a diameter of 12 mm., J inch. The ovarian and 
uterine veins are proportionally enlarged. The lymph- 
tubes reach the size of goose-quills and the lymph-spaces 
are expanded. Hypertrophy of the nervous structures 
keeps pace with the general uterine development. 

Changes in the Cervix Uteri. Size. — The apparent 
shortening of the cervix during pregnancy is due partly to 
softening of its structure and partly to swelling of the 
vaginal mucosa and the loose cellular tissue about the 
cervix at the vaginal junction. The cervical enlarge- 
ment is partly hypertrophic, but is mainly due to loosen- 
ing of its structure in consequence of serous infiltration ; 
it is progressive to about the end of the eighth month. 

Structure. — Softening extends progressively from the 
lower border upward ; it involves the entire cervix by the 
end of the eighth month. By this time generally the cer- 
vical canal has become sufficiently expanded in multipara? 
to admit the finger, and the head of the child may be felt 
through the membranes. In women pregnant for the first 



72 ESSENTIALS OF OBSTETRICS 

time the os externum is seldom as large as the finger, even 
in the later weeks of gestation. 

Changes in other Pelvic Structures. — The uterine 
peritoneum is developed by tissue-growth proportionately 
to the development of the uterus itself. 

The broad ligaments adapt themselves to the expansion 
of the uterus partly by the separation of their layers and 
partly by growth in the number and size of their tissue- 
elements. 

The ovaries and the Fallopian tubes lie in contact with 
the sides of the uterus by the time it rises out of the lesser 
pelvis. 

The vagina undergoes hypertrophy during pregnancy. 
The width and length of its walls are increased and it be- 
comes more vascular. 

General Changes. The Heart. — According to most 
authorities there is a physiological hypertrophy of the 
left ventricle of the heart during gestation, which is de- 
signed to meet the increased resistance in the systemic 
circulation brought about by the superadded utero-pla- 
cental circulation. The pulse-rate is slightly accelerated. 

The Blood. — The total volume of blood is increased in 
the latter half of pregnancy. There are an increase in 
the proportion of white globules and a diminution in that 
of the red corpuscles and albumin. In the later months 
there is more fibrin. The proportion of water is normally 
little greater than in the non-gravid state. Extreme 
changes in the blood do not occur in normal pregnancy. 

The Nervous System. — In most gravida? there is a marked 
increase in the irritability of the nervous system. Psychic 
disturbances, neuralgias and other nervous disorders are 
frequently observed. 



PHYSIOLOGY OF PREGNANCY. 73 

The Body-weight. — As a rule, a considerable gain in 
body-weight occurs in the later months, due mainly to in- 
creased adipose deposit. 

The Thyroid. — The thyroid gland is hypertrophied dur- 
ing pregnancy, and to a certain degree the enlargement 
remains permanent. 

Similar changes also occur in the liver, spleen and, 
probably, in the kidneys. 

SIGNS OF PREGNANCY. 

A. HISTORY. 
Suppression of Menses. — In a woman of previously reg- 
ular menstrual habit, and in the absence of other appre- 
ciable causes of amenorrhoea, the arrest of the catamenia 
is to be regarded as strong presumptive evidence of preg- 
nancy. Other possible causes of suppression must, how- 
ever, be excluded. These are : 

Anaemia ; Change of climate ; 

Tuberculosis ; Tardy menstruation ; 

Chronic nephritis ; The menopause ; 

Exposure to cold; Emotional causes. 

This sign is not in all cases available for diagnosis. 
Conception may take place during the physiological amen- 
orrhoea of lactation or before the menstrual function is 
established. In a few recorded cases pregnancy has 
occurred after the menopause. On the other hand, pe- 
riodical hemorrhages simulating menstruation are some- 
times observed in the early months of pregnancy. The 
bleeding in such cases generally proceeds from polypi or 
other lesions of the cervix, from chronic decidual endo- 
metritis or from placenta prsevia, and its occurrence at the 



74 ESSENTIALS OF OBSTETRICS. 

end of the menstrual month results from the influence of 
the menstrual molimen. Usually it may be distinguished 
from menstruation by the irregularity in the amount and 
duration of the flow. The typical menstrual discharge 
begins and ends gradually, and in the intervening time is 
nearly constant in quantity. The usual length of the 
menstrual period is four or five days. Bleeding from 
other causes seldom presents these characteristics. 

Nausea is present for a time in the vast majority of preg- 
nancies. Usually it begins about the end of the first 
month 1 and ceases by the end of the third, when the uterus 
rises out of the true pelvis. It may subside earlier or 
last longer ; in exceptional instances no nausea is ex- 
perienced during the entire period of pregnancy. 

Generally it is a morning sickness. Sometimes it per- 
sists throughout the day. Pathological causes, such as 
chronic nephritis and chronic gastric catarrh, may simulate 
the morning sickness of pregnancy, and these must be 
excluded. 

Ptyalism in greater or less degree frequently accompanies 
the nausea. Excessive salivation is exceptional. 

Hypersecretion of mucus in the mouth and throat dur- 
ing the early months of gestation is more common. The 
tenacity of the secretion and the difficulty of expectoration 
have given rise to the term " spitting cotton. " 

Certain mammary and abdominal signs may be brought 
out in the history, such as enlargement, a sense of weight, 
fulness and tenderness of the breasts, growth and pigmen- 
tation of the abdomen and quickening. 

x By the term month the calendar month is meant unless otherwise 
specified. 



PHYSIOLOGY OF PREGNANCY. 75 

B. PHYSICAL SIGNS. 
1. Mammary Changes. 

(a) Increased Size and Fulness of the Glands. — The 
milk-glands are enlarged by growth of the acini, swelling 
of the connective tissue and by interlobular deposit of fat. 
Development of the gland must be distinguished from 
overlying fat. The gland is readily identified on palpa- 
tion by greater density and by its nodular border. 

The fulness and firmness are not always well marked 
after mid-pregnancy. Rarely no material enlargement is 
observed during the entire period of gestation. 1 

(b) Primary Areolae. — Important changes take place in 
the areolae. They become pigmented, elevated and oedem- 
atous. The depth of pigmentation varies according to the 
complexion of the patient. It is faintly developed in 
blondes, well marked in brunettes, and in the negress is 
nearly black. Sometimes it shades into the color of the 
surrounding skin at the upper and outer aspects of the 
areolae toward the end of the second month. The areolae 
acquire a soft, velvety feel and are slightly raised above 
the general level of the skin. The most significant of 
these changes in the primary areolae is the pigmentation. 
(Fig. 23.) 

(c) Montgomery's follicles are sebaceous follicles of the 
areolae, ten to twenty in number in each, which have be- 
come hypertrophied during pregnancy. They appear as 
papular elevations within the primary areolae. They are 
best displayed while the skin is held gentlv on the stretch. 
(Fig. 23.) 

tinman calls attention to the fact that slender cords (hypertrophic 
acini) may be felt radiating from the nipple before the milk secretion 
begins. 



76 



ESSENTIALS OF OBSTETRICS. 



(d) Enlargement of Veins. — The superficial veins of the 
breasts become fuller and more prominent. On slightly 
stretching the skin in a good light veins may be seen 



Fig. 23. 




The primary and secondary areolae of pregnancy. 

coursing across the areolae. (Fig. 23.) Frequently a vein 
is seen encircling each primary areola at its margin. 

(e) Milk Secretion. — Colostrum may be pressed from 
the nipples at the end of the third month. In women 
who have never borne children its presence affords pre- 
sumptive evidence of pregnancy. Yet rarely milk secre- 



PHYSIOLOGY OF PREGNANCY. 11 

tion is possible in virgins, sometimes even in males. The 
sign is of no value after the first pregnancy, since usually 
milk may be found in the breasts of parous women. 

To elicit this sign the manipulation should begin over 
the ampullae of the milk-ducts at the base of the nipple. 

(/) Secondary Areolae. — These are faintly pigmented 
zones skirting the primary areolae. (Fig. 23.) They are 
characterized by one or more rows of feebly marked cir- 
cular spots just without the primary areolae. The mark- 
ings are due to non-pigmented sebaceous follicles. In 
women never pregnant before, the secondary areolae are 
diagnostic when well made out. 

Date of Appearance of Mammary Signs. — All the mam- 
mary signs, with two exceptions, may be looked for by the 
close of the second month. Colostrum is present at the 
third, and the secondary areolae appear at the fifth month. 

Diagnostic Value. — In primigravidae the mammary 
changes usually afford sufficient evidence for, at least, a 
presumptive diagnosis of pregnancy. In women who 
have borne children they are not to be relied on since 
most of them once developed remain more or less perma- 
nent. 

The group of mammary signs is rarely complete and 
those present are seldom equally well developed. 

Breast-changes similar to those of pregnancy may re- 
sult from pelvic disease. Pathological conditions of the 
sexual organs which may cause reflex mammary changes 
must, therefore, be excluded. 

2. Abdominal Signs. 
1. Inspection. («) Flattening. — In the second month 
of gestation the abdomen is slightly flattened ; the uterus 



78 ESSENTIALS OF OBSTETRICS. 

during this period sinks somewhat lower in the pelvis and 
the hypogastrium is therefore a little less prominent. 

(b) Enlargement of the abdomen is apparent after the 
third month, when the uterus begins to rise out of the lesser 
pelvis ; thereafter it increases with the growth of the uterus 
till the middle of the ninth month. Within two weeks or 
more before term the uterus usually sinks deeper in the 
pelvis and the waist-line becomes perceptibly smaller. 

(e) Pigmentation. — As a rule pigmentation of the abdo- 
men is limited to a narrow band about 3 mm., J inch, in 
width extending from the pubes to the umbilicus, some- 
times to the en si form. It is present by the end of the 
second month. Pigmentation of the abdomen, like that 
of the breasts, varies in depth and extent of surface with 
the complexion of the patient. In brunettes a dark circle 
appears around the umbilicus, and pigmented patches are 
observed over other parts of the abdomen. In blondes 
entire absence of pigmentary changes is not infrequent. 
Deposits of pigment similar to those of pregnancy are 
sometimes observed in other conditions of health and 
disease. 

(d) Umbilical Changes. — The umbilicus is retracted in 
the first three mouths and becomes protruded in the last 
two or three. 

(e) Linese Albicantes, or Striae Gravidarum. — These are 
irregular whitish, pinkish or bluish lines developed over 
the lower half of the abdomen during the later months of 
pregnancy. Sometimes they may be observed on the hips 
and thighs. The breasts may present similar markings. 
Usually they are slightly depressed below the general sur- 
face of the skin. They are due chiefly to partial atrophy of 
the skin from tension ; they appear at about the sixth month. 



PHYSIOLOGY OF PREGNANCY. 79 

Once formed they remain in greater or less degree perma- 
nent. Distention of the abdomen from causes other than 
pregnancy may give rise to similar changes. 

•2. Palpation, (a) Size of the Tumor. — The fundus 
uteri lies nearly in the plane of the pelvic brim at the third 
month, reaches the level of the umbilicus by the sixth and 
the ensiform cartilage at the thirty-eighth week. More 
accurate for our purpose than the situation of the fundus 
are the width and length of the uterus. For the uterine 
measurements at different stages of gestation see table on 
page 70. 

(6) Character of Tumor. — The gravid uterus is normally 
a smooth, symmetrical, pyriform or ovoid, fluid tumor. 
In the second month when relaxed the body of the uterus 
is so soft and flaccid as to be almost imperceptible by pal- 
pation. In the last trimester, and even earlier, foetal 
parts may be made out by abdominal palpation. They 
are readily felt in the second trimester by the usual bi- 
manual palpation. 

(c) Intermittent contractions of the uterus may be de- 
tected by the fourth month by abdominal palpation, at an 
earlier period by the bimanual examination. They recur 
at intervals of five or ten minutes ; may be obtained im- 
mediately by applying the hand cold, or by the use of 
gentle friction over the tumor. They are not abolished by 
the death of the foetus. H^ematometra, hydrometra, dis- 
tended bladder aud soft fibroids, in all of which contractions 
may occur, must be excluded. 

The value of this sign, to which much importance was 
formerly attached, is vitiated by the fact that contractions 
take place in the non-gravid uterus. 

(d) Active Foetal Movements. — 1. As an objective sign, 



80 ESSENTIALS OF OBSTETRICS. 

active movements of the fetus afford conclusive evidence 
of pregnancy. This sign is available by abdominal pal- 
pation about the fourth month. It is most promptly 
elicited by applying the hand cold to the abdomen or by 
tossing the foetus from side to side. Muscular move- 
ments of the foetus begin about the tenth week, and some- 
times may be detected by the bimanual examination as 
early as the twelfth. In hydramnios, and in certain 
other conditions, detection of foetal movements is difficult 
and often impossible. In occasional instances they may 
be absent for a time from no apparent cause. 

2. As a subjective sign the foetal movements are not 
always reliable. In neurotic women they may be simu- 
lated by intestinal flatus, spasmodic contractions of the 
abdominal muscles and certain other conditions. 

The sensation of foetal movements, as first felt by the 
mother, is termed quickening. The period of quickening 
is usually the end of the fourth month ; yet it varies from 
the twelfth to the twentieth week. Rarely the foetal 
movements are not felt by the mother during the entire 
period of pregnancy. 

(e) Passive Foetal Movements ; External Ballottement. — 
External ballottement is practised by placing the hands 
over the sides of the abdomen with their palmar surfaces 
facing each other and tossing the foetus from hand to hand. 
Pathological growths floating in ascitic or other fluid must 
be excluded. 

3. Auscultation, (a) The funic or umbilical souffle is 
a bruit synchronous with the foetal pulse. It is heard in 
but few cases, and only in the later months. The bruit 
results from partial compression of the cord, impeding the 
blood-current. 



PHYSIOLOGY OF PREGNANCY. 81 

(6) The uterine souffle is a subdued murmur synchro- 
nous with the mother's pulse. It is usually best heard 
over the lateral aspects of the uterus, especially the left, 
since owing to the usual right torsion of the gravid uterus 
the left border is most readily accessible. It is generally 
audible after the fourth month ; it may sometimes be de- 
tected earlier by pressing the stethoscope deeply down at 
the side of the uterus. The sound originates in the as- 
cending uterine arteries and their branches, and not in the 
placental sinuses, as once believed. It persists after the 
delivery of the placenta. In other conditions which give 
rise to enlargement of the uterine arteries and to increased 
blood-current in these vessels a similar souffle may be 
heard. Thus the bruit is commonly present with uterine 
myomata, chronic metritis and even with ovarian cysts. 

(c) The choc foetal is the shock of a foetal movement as 
perceived by the ear on auscultation of the abdomen over 
the uterus. It resembles the effect produced by gently 
percussing one hand held flat against the ear with a finger 
of the other hand. The bruit de choc foetal is a murmur 
that immediately precedes the choc foetal, owing to dis- 
placement of liquor amnii by the foetal movements. 

(d) The foetal heart-tones are generally perceptible by 
abdominal auscultation at the fourth or fifth month 8 By 
vaginal stethoscopy they may sometimes be heard at the 
twelfth week. 

The heart-sounds resemble those of the newborn infant 
heard through several thicknesses of clothing. The rate is 
nearly double that of the maternal pulse, 120 to 150 per 
minute. They are audible over an area of three inches or 
more in diameter. The point of greater intensity is termed 
the focus of auscultation. Usually this nearly overlies the 



82 ESSENTIALS OF OBSTETRICS. 

lower angle of the left foetal scapula. Exceptionally there 
may be a second focus, even in single fcetation, due to con- 
duction through some remote point of foetal contact with 
the uterine wall. The heart-sounds may for a time be in- 
audible, owing to dorso-posterior position of the foetus, 
hydramnios or to other causes. Their persistent absence 
usually may be taken as evidence of foetal death. 

Method of Examining. — Place the patient in the hori- 
zontal position in a still room. Auscultate by the me- 
diate or the immediate method — in other words, with or 
without the stethoscope. Listen over the assumed or pre- 
viously ascertained location of the left foetal scapula. Fail- 
ing there, search the entire surface of the tumor. Press 
the abdominal walls firmly against the tumor ; a continu- 
ous solid medium favors conduction. In dorso-anterior 
positions, crowding the breech downward in the axis of 
the foetus helps by arching the child's back forward. Fail- 
ing, try again at intervals of a few hours or days. 

A succession of sounds of the characteristic quality and 
rhythm, with a rate double that of the maternal pulse, and 
which can be counted, establishes the diagnosis of preg- 
nancy. 

3. Pelvic Signs. 

(«■) Purplish Color of the Vagina (Jacquemin's sign). — 
The vagina takes on a purplish hue, which varies greatly 
in depth in different individuals, and varies in the same 
individual at different stages of gestation. Usually a 
venous color is faintly developed by the end of the first 
month. It is most constantly observed in the anterior 
vaginal wall immediately below the meatus urethrse. The 
cause of the deepening color is chiefly, at least, hyper- 
trophy of the corpus cavernosum of the vestibule and of 



PHYSIOLOGY OF PREGNANCY. 83 

the vaginal venous plexuses. It is to be found in about 
80 per cent, of cases of pregnancy by the end of the third 
month. Pathological congestion must be excluded, since 
the color in pregnancy is not distinguishable from that 
which is produced by pelvic congestion in disease. 

Purplish Color of the Cervix. — A more or less marked 
livklity of the vaginal portion of the cervix may be ob- 
served almost from the first month after conception. The 
purplish hue of the cervix is not only developed earlier, 
but it is more constantly present than is that of the vagina. 
Here, too, morbid causes must be excluded. 

(6) Softening of the cervix can usually be made out by 
the touch at the sixth week. At this early stage of gesta- 
tion the softened portion is a thin stratum over the lower 
border of the cervix ; it presents the feel of a thin velvety 
layer covering the firm body of the vaginal portion. As 
pregnancy advances the cervical softening progresses from 
below upward and it involves the entire cervix by the end 
of the eighth month. The cervical canal becomes more 
patulous as the softening extends. These changes are 
not always well defined in the early months. Similar 
softening may arise from pathological causes, but it then 
lacks the progressive character which belongs to that of 
pregnancy. 

(c) Changes in the Uterine Tumor. — The most conclusive 
evidences of pregnancy in the second and third months 
are the alterations in size, shape and consistence of the 
uterus as detected by bimanual examination. The body 
of the uterus grows with the growing ovum, it takes on 
an irregularly globular shape and acquires a soft, elastic 
feel. These changes are well marked by the sixth week 
and they may sometimes be recognized at an earlier period. 



84 ESSENTIALS OF OBSTETRICS. 

Most significant are softening and enlargement of the 
body of the uterus. When relaxed the body is markedly 
fattened antero-posteriorly, and in the second month much 
expanded laterally. In contraction, which soon develops 
under manipulation of the examining fingers, it becomes 
somewhat globular or ovoid in shape. 

Chronic metritis or subinvolution is distinguished from 
utero-gestation by greater density, absence of growth and 
by the history. 

An anteflexed and hypersemic uterus may resemble the 
gravid tumor in shape and consistence, but it, too, is dis- 
tinguished from pregnancy by the absence of growth. 

A soft submucous fibroid can generally be differentiated 
by the history and by the slower rate of enlargement. 

Hydrometra and ha^matometra present the usual char- 
acters of a tense cyst. They are extremely rare. 

Hegar's Sign. — One of the most striking characteristics 
of the uterus in the second month of gestation is the 
compressibility of the isthmus uteri, known as Hegar's 
sign. It is especially marked in the median portion 
of the isthmus, which in the non-gravid state is the 
most dense. 

Method of Examining for Hegar's Sign. — The patient 
lies in the lithotomy position. The uterus is depressed 
by the external hand, or is drawn down with a volsella 
caught in the cervix. The thumb of the other hand is 
carried into the vagina and pressed against the lower 
uterine segment at its junction with the cervix. A finger 
of the same hand is passed into the rectum to a point 
just above the utero-sacral cul-de-sac. The uterine tis- 
sues between the thumb and finger may be compressed 
almost to the thinness of a postal card. Thinning under 



PHYSIOLOGY OF PREGNANCY. 85 

pressure to less than a half centimeter (0.2 inch) estab- 
lishes the diagnosis of pregnancy. 

The examination may be facilitated by the aid of an- 
aesthesia and by first distending the lower rectum with 
water. 

The compressibility of the isthmus may be made out by 
catching it between the index finger of one hand in the 

Fig. 24. 



Bimanual examination for Hegar's sign ; uterus tilted forward. (Sonktag.) 

anterior, and of the other in the posterior vaginal fornix, 
the uterus being drawn gently down with a volsella. 
Usually it can be done satisfactorily by the ordinary bi- 
manual manipulation. 

In examining by conjoined manipulation the uterus may 
be tilted either forward or backward, and the isthmus thus 



86 ESSENTIALS OF OBSTETRICS. 

be brought between the examining fingers. (Figs. 24 
and 25.) 

(d) Pulsation of the uterine artery is perceptible to the 
touch from the first month of pregnancy. The examining 
finger is held against the vaginal wall at one side of the 

Fig. 25. 




Bimanual examination for Hegar's sign ; uterus tilted backward. (So>~>tag. ) 

cervix. Pathological growths may give rise to hyper- 
trophy of the artery and must be excluded. 

(e) The temperature of the cervix is from J° to |° F., 
above that of the vagina or the rectum. This may result, 
too, from local inflammatory causes. 

(/) Internal ballottement ; passive foetal movements. — 
Ballottement is available during the fifth and sixth 
months. Earlier the weight of the foetus is too small, 



PHYSIOLOGY OF PREGNANCY. 87 

later generally its mobility is too limited to permit of 
ballottement. 

Method. — The patient assumes the reclining (half-sit- 
ting) or the erect posture, the bladder must be empty 
and the clothing loose. Two fingers in the vagina are 
held agaiust the anterior uterine wall above the cervix, 
the other hand steadying the fundus. The foetus tossed 
upward falls again, and taps the finger. 

Distinguish from : Anteflexed uterus, a pedunculated 
tumor of the ovary or uterus, internal projections of large 
cysts, a floating kidney low-down, stone in the full blad- 
der, pulsation of the uterine artery. 

Ballottement may fail from scanty liquor amnii, ab- 
dominal presentation of the foetus, placenta praevia, mul- 
tiple fcetation, etc. 

Summary of Diagnostic Signs. 

The mammary signs collectively in first pregnancies ; 

Detection of foetal parts ; 

Active foetal movements ; 

Changes in the uterine tumor ; 

Internal ballottement ; 

Foetal heart. 

Abdominal Enlargement from other Causes. 

Abdominal enlargement from other causes than gestation 
is distinguished from it by the absence of the diagnostic 
signs of pregnancy, especially those which pertain to the 
uterus. The non-gravid tumors of the abdomen also 
present certain characters of their own by which, as a 
rule, they may be differentiated from gestation. 

Hcematometra and Hudrometra, which may simulate 
pregnancy, have already been alluded to. 



88 ESSENTIALS OF OBSTETRICS. 

Fat in- the abdominal wall may be caught up in folds 
with the hand and moved about over the underlying mus- 
cles, the patient being in the dorsal-recumbent position. 

A phantom tumor vanishes under anaesthesia. 

Tympanites usually subsides in the morning, percussion 
is resonant and palpation negative. The abdominal walls 
can be pressed backward against the vertebral column. 
Place the patient in the horizontal position and ask her 
to breathe deeply. Maintain firm pressure with the finger- 
tips on the abdomen. With each expiration the walls 
sink deeper until they touch the vertebral column. 

In ascites, frequently the abdomen is flattened at the 
umbilicus when the patient lies in the horizontal position. 
Percussion is tympanitic at the summit of the tumor, ex- 
cept in rare instances, in which the mesentery is too short 
to permit flotation of the intestines to the surface of the 
fluid. There is dullness throughout the flanks. 

A fluid wave can be transmitted through all parts of 
the tumor within the limits of the fluid. In pregnancy 
the wave is intercepted by the foetus. The fluid-level 
changes with the posture of the patient. 

In ascites evidence usually may be detected of the 
pathological condition which has given rise to the hydro- 
peritoneum. 

Tumors of other organs may be traced to the normal 
location of those organs, and the uterus is readily differ- 
entiated from the tumor. 

In ovarian cystoma, as a rule, there is more pronounced 
fluctuation than in the tumor of pregnancy. There is, too, 
absence of foetal parts, of active foetal movements and of the 
foetal heart. In most cases the uterus may be mapped out 
apart from the tumor. The menses are usually not absent. 



PHYSIOLOGY OF PREGNANCY. 89 

Uterine myomata, when of the submucous variety, are 
distinguished from pregnancy by menorrhagia and gener- 
ally by greater density. 

Subperitoneal myomata are distinguished by the nodular 
character of the tumor. 

The growth in either variety is not so rapid as in gesta- 
tion and the uterus is denser than in pregnancy. Preg- 
nancy sometimes coexists with myomata or other pelvic 
or abdominal neoplasms, and then is often extremely diffi- 
cult of recognition. 

It must be remembered that a uterine bruit like that 
of pregnancy may be heard in a myomatous uterus. 

Multiple Pregnancy. 

Twins occur once in about eighty or ninety pregnancies, 
triplets once in seven or eight thousand. Quadruple and 
even quintuple pregnancies are sometimes met with. A 
case of sextuple pregnancy is recorded. 

Multiple foetation borders on the pathological. The 
viability of the children is lower than in single preg- 
nancy. Usually the foetuses are of undersize and of un- 
equal development. Acephalous monstrosity and mal- 
presentation are more common than in single pregnancy. 
Death of one or both in utero is not infrequent. Gener- 
ally twin pregnancy is attended with excess of liquor 
amnii. In two-thirds of the cases labor comes on pre- 
maturely. 

Origin of Multiple Pregnancy. — Multiple pregnancy 
may result from rupture of two or more Graafian follicles 
at the same menstrual period, either in the same or in 
different ovaries, from two ova in one follicle, or from a 
single ovum with a double germ. Children from the 



90 ESSENTIALS OF OBSTETRICS. 

same ovum are always of the same sex. Hence the mem- 
bers of a double monstrosity are alike in sex. 

Arrangement of the Membranes and Placentas. — In twin 
foetation from separate ovules there are two amnions, two 
chorions and two placentas. The placentas may be sepa- 
rate or fused at their margins. In either case they have 
independent circulations. 

In twin pregnancy from a single ovum having a double 
germ there is a single chorion containing two amnions ; 
almost invariably the placenta is single. Rarely two 
foetuses are found in a common sac, the amniotic septum 
having been destroyed. 

Superfecundation. — Superfecundation is a twin preg- 
nancy resulting from separate acts of insemination by the 
same or different males of ova expelled at the same period 
of ovulation. 

Superfcetation. — This term was formerly applied to a 
twin pregnancy which was believed to result from the im- 
pregnation of two separate ova thrown off at different 
periods of ovulation. Supposed cases of this character are 
doubtless to be explained as twin pregnancies in which 
one foetus is blighted. 

Duration of Pregnancy. 

The duration of pregnancy is not definitely known, and 
it probably never can be, since the time of fecundation is 
unknown. 

The average period between the beginning of the last 
menstruation and labor is two hundred and eighty days, 
practically ten menstrual months. 

The average interval between the fruitful coitus and the 
birth of the child is two hundred and seventy-three days. 



PHYSIOLOGY OF PREGNANCY. 91 

Variations of twenty days above or below these averages 
are doubtless possible within physiological limits. Much 
variation, however, in the actual period of gestation, with 
the exception of cases in which the pregnancy is cut short 
by accident, is probably extremely rare. The term of 
pregnancy is frequently shortened a few days, or even one 
or two weeks, with nothing in the character of the labor 
or the appearance of the child which would suggest to 
casual examination a premature birth. So insecure is the 
attachment of the ovum in the last week or two of gestation 
that doubtless labor is established prematurely in a large 
proportion of instances. On the other hand the pregnancy 
may appear to be prolonged when in reality the actual 
term of gestation has not exceeded the usual normal limit. 
It is not infrequently the case that conception dates, not 
from the end of the week following the beginning of the 
last menstrual flow as is usually the rule, but from some 
later period in the month. An error of two or three weeks 
in the count often is thus possible. 
Rules and Methods for Predicting the Date of Labor. 

(a) Naegele's Rule. — Compute nine calendar months 
from the beginning of the last menstrual period and add 
seven days. This is a ready method of reckoning ap- 
proximately two hundred and eighty days from the be- 
ginning of the last menstruation. For predicting the date 
of labor it is generally accurate within a week. It is 
subject, however, to the fallacies already pointed out. 

Reckoning from the date of quickening is not reliable. 
The period of quickening is not constant. It varies in 
different individuals, and even in the same individual in 
different pregnancies. Moreover, the observations of the 
patient in this matter are often fallacious. 



92 ESSENTIALS OF OBSTETRICS. 

(6) Mensuration of the uterus is not a wholly reliable 
basis for prediction, since the quantity of liquor amnii 
varies in different cases and the size of the foetus at a given 
period of gestation is not constant. 

Situation of the Fundus. — The fundus uteri is in the 
plane of the brim at the third month, at the umbilicus 
about the sixth and reaches the ensiform cartilage at eight 
and one-half months. At lightening it sinks to a little 
lower level. Accuracy here, too, is vitiated by the causes 
just mentioned and also by the fact that the umbilicus is 
not a fixed point. 

(c) Mensuration of the Foetus. — The total length of the 
foetus is about double that of the foetal ovoid. The latter 
may be measured with sufficient accuracy with a pelvim- 
eter, placing one knob in contact with the lower foetal pole 
through the vagina and the other upon the abdomen over 
the upper pole, or measuring externally, through the ab- 
dominal wall. The rate of foetal development, however, 
is not uniform ; extreme accuracy of measurement, too, is 
impossible. Yet this measurement together with the 
diameters of the head affords fairly reliable data for esti- 
mating the stage of pregnancy. 

Length of the Foetus. 

The approximate lengths of the child in different stages 
of intrauterine development during the later months of 
gestation are as follows : 

Sixth calendar month, 30 to 35 cm., 12 to 14 inches. 

Seventh calendar month, 35 to 40 cm., 14 to 16 inches. 

Eighth calendar month, 40 to 45 cm., 16 to 18 inches. 

Ninth calendar month, 45 to 50 cm., 18 to 20 inches. 



PHYSIOLOGY OF PREGNANCY. 93 

HYGIENE OF PREGNANCY. 

The patient should seek the advice of her physician 
from the early months of gestation. She should consult 
him on even slight departures from health and especially 
during the later months. 

Hygienic Requirements are : Exercise in the open air 
an hour or two daily, with care to avoid over-exertion and 
exhaustion ; the avoidance, if possible, of all injurious 
mental influences; the observance of regular hours for 
meals ; proper quantity and kind of food ; daily bowel 
movements ; eight hours sleep daily ; pure air constantly ; 
a tepid or cold sponge-bath daily. 

The teeth are especially prone to decay during preg- 
nancy and special care, should, therefore, be given them. 
They should be cleansed on rising and retiring and after 
each meal. Occasional inspection by the dentist is ad- 
visable. 

In cases of irritating leucorrhoeal secretions a vaginal 
injection of a quart of water at a temperature of 98° F., 
or of a borax solution, §ss ad Oj, may be used once or 
twice daily. The temperature of the douche should be 
that of the body and the injection must be given with the 
least possible force lest it provoke abortion. 

Diet. — The diet throughout pregnancy should consist 
of easily digestible food and the quantity should be mod- 
erate. Milk, eggs, bread, fruits, with fish occasionally, 
are suitable. Meat should not be taken oftener than once 
daily. Fried dishes, pastry, and rich food of whatever 
description should be avoided. 

Clothing. — In our climate light flannel underwear is 
essential at all seasons ; the outer clothing must be changed 



94 ESSENTIALS OF OBSTETRICS. 

to suit changing temperatures. A rational method of dress 
requires no more clothing for indoor use in the winter 
months than would be needed at the corresponding tem- 
perature in the summer season. For outdoor use extra 
wraps are called for according to the degree of exposure 
to cold. 

The clothing must not be tight, especially about the 
breasts and abdomen, and the heavier garments should 
be suspended from the shoulders. 

Care of the Nipples. — It is a useful practice to cleanse 
the nipples daily with a borax solution, 5ss ad Oj, during 
the last two months of pregnancy. They may be anointed 
with fresh cacao butter after cleansing, and if they are 
small or sunken the patient should be taught to draw 
them out with the thumb and fingers. Astringent applica- 
tions such as are frequently employed with a view to hard- 
ening the nipples doubtless tend rather to promote crack- 
ing during lactation than to prevent it. The better practice 
is to keep them supple by the use of inunctions. The 
manipulation referred to not only helps to develop the 
nipples when this is required but it has the further effect 
of inuring them to nursing. 

The Urine. — The urine should be examined chemically 
and microscopically at least once monthly during the first 
seven months, once a week during the last two months, of- 
tener in the presence of toxaemia, oedema, of renal insuf- 
ficiency or evidence of nephritis. 

In all observations of the urinary excretion the specific 
gravity and the quantity passed daily are essential as indi- 
cating the extent to which toxic material is being elimi- 
nated. It should not be less than 50 or 60 ounces. 
Quantitative tests for urea afford the best evidence of 



PHYSIOLOGY OF PREGNANCY. 95 

the functional activity of the kidneys. The average nor- 
mal quantity of urea daily is about 33 grammes, 500 
grains, of the total solids daily about Q6 grammes, 1000 
grains. The total solids may be roughly estimated by 
multiplying the last two figures in the number indicating 
the specific gravity by the number of ounces of urine and 
the product by 1.10. For the estimation of urea Bart- 
ley's method is recommended. 1 

When the daily quantity of urine falls below 60 ounces 
the ingestion of a larger quantity of water is indicated. 

Marital Relations. — Marital relations are to be re- 
stricted, particularly at the menstrual dates. Violation 
of this rule is a common cause of abortion and of prema- 
ture labor. The nausea of pregnancy is often aggravated 
by this cause. 

1 Bartley's Medical Chemistry. 



CHAPTER III. 
PHYSIOLOGY OF LABOR. 

1. THE MECHANICAL FACTORS OF LABOR. 

Three factors are concerned in the mechanism of child- 
birth, the powers, the passages and the passenger. 

1. The Expelling Powers. 

The expelling powers are : 

1. The Muscular Action of the Uterus. — This is involun- 
tary, the motor apparatus of the uterus being chiefly con- 
trolled by the sympathetic nervous system. The uterine 
contraction is peristaltic, yet practically simultaneous ; it 
begins at the fundus probably. 

2. The action of the abdominal muscles, which is partly 
voluntary, partly a reflex, involuntary contraction. 

In the expulsive stage of labor the contractions of the 
abdominal muscles are usually brought into play indepen- 
dently of volition. Their force may generally be aug- 
mented by voluntary effort. They have the effect to in- 
crease the intra-abdominal pressure and thus to reinforce 
the expulsive action of the uterus. 

The chief expellant force is the contraction of the 
uterus. Contractions of the muscular elements of the 
round and of the broad ligaments take place at the same 
time with the uterine contraction. They help to steady 
the uterus in the axis of the pelvis. 



PHYSIOLOGY OF LABOR 97 

The power of the uterine contraction reinforced by that 
of the abdominal muscles according to Duncan is 50 to 80 
pounds ; according to Schatz it is from 17 to 55 pounds. 

2. The Passages. 
The passages include : 1. The hard parts of the bony 
pelvis. 2. The soft parts, consisting of the uterus, the 
pelvic floor and the structures which line the osseous por- 
tion of the birth-canal. 

Obstetric Anatomy of the Bony Pelvis. 

The Pelvis. — The pelvis is a strong, bony basin, 
whose cavity is the most important portion of the par- 
turient tract. 

The constituent parts of the bony pelvis are the two ossa 
innominata, the sacrum and the coccyx. 

The joints are the symphysis pubis, the sacro-iliac joints 
and the sacro-coccygeal joint. A slight mobility of the 
pubic and the sacro-iliac joints is usually present in the 
later months of gestation. The capacity of the pelvis is 
thus a little larger than in the non-gravid state. 

Extension of the thighs moves the upper end of the sa- 
crum backward and favors the passage of the head through 
the pelvic brim. The escape of the head from the pelvis 
at a later stage of the labor is promoted by flexion of the 
thighs upon the abdomen, which carries the lower end of 
the sacrum backward. 

Recession of the coccyx to the extent of 12 mm. to 25 
mm., J to 1 inch, occurs during the expulsion of the foetal 
head from the outlet. 

The false pelvis or greater pelvis is that portion of the 
pelvis above the ilio-pectineal line. It forms with the 
7 



98 



ESSENTIALS OF OBSTETRICS. 



lower part of the abdominal wall a funnel-shaped ap- 
proach to the true pelvis. 

The true pelvis or lesser pelvis is the part of the pelvis 
below the ilio-pectineal line. It is with this that obstetric 
questions are mainly concerned. 

The brim, inlet, superior strait, margin or isthmus of the 
pelvis is located by the ilio-pectineal line and the upper 
margin of the sacrum. Usually it is approximately heart- 
shaped. Sometimes it is oval or nearly round. 

Fig. 26. 




Brim of pelvis. 1. True conjugate. 2. Transverse diameter. 3. Oblique diameter. 
4. Greater saero-seiatic foramen. 5. Lesser sacro-sciatic foramen. 

Obstetric landmarks at the brim are : (1) The sacral 
promontory or sacro-vertebral angle ; (2) The sacro-iliac 
joints ; (3) The ilio-pectineal eminences, which are situ- 
ated at the ilio-pubic joint, on the pubic bone ; (4) The 
symphysis pubis. 

The outlet of the pelvis, or inferior strait, is lozenge- 
shaped, and is located by the tip of the coccyx, the sub- 
pubic arch and the ischial tuberosities. It is made up of 
two obtuse-angled triangles, whose common base is a line 



PHYSIOLOGY OF LABOR. 99 

joining the ischial tuberosities ; the apex of the one is the 
summit of the subpubic arch j the apex of the other is the 
tip of the coccyx. 

Obstetric land marls at the outlet are : (1) The tip of the 
coccyx; (2) The subpubic arch, formed by the descend- 
ing rami of the pubic bones; (3) The ischial tuberosities; 
(4) The ischial spines; (5) The greater and the lesser 
sacro-sciatic ligaments which help to supplement the bony 
canal. 

Fig. 27. 



Outlet of pelvis. 

The greater sacro-sciatic ligaments spring from the pos- 
terior-inferior spines of the ilium and from the sides of the 
sacrum and the coccyx and are inserted into the inner sur- 
faces of the ischial tuberosities. 

The lesser sacro-sciatic ligaments lie in front of the 

greater. They arise from the sides of the sacrum and the 

coccyx and are inserted into the ischial spines. The open 

space between the lesser sacro-sciatic ligament and the 

ilium and ischium is the greater, that between the two 

ligaments and the bone in front is the lesser sacro-sciatic 

foramen, . - 
Lot C. 



100 ESSENTIALS OF OBSTETRICS. 

The greater sacro-sciatic foramen transmits the pyri- 
formis muscle, and the gluteal, the sciatic and the pubic 
vessels and nerves. 

The lesser sacro-sciatic foramen transmits the tendon of 
the obturator intern us muscle and the internal pudic 
vessels and nerves. 

The cavity of the pelvis is bounded posteriorly mainly 
by the sacrum and the coccyx ; anteriorly by the pubic 
bones and the ischio-pubic rami ; laterally by the surfaces 
of the iliac and the ischial bones. 

The posterior wall is smooth, and is concave from above 
downward, a fact which favors the descent of the posterior 
pole of the foetal head or other presenting part. The 
depth of the posterior Avail is 12.5 cm., 5 inches ; if 
measured on the curve of the sacrum and coccyx, 14 cm., 
5J inches. The anterior wall is smooth and concave 
from side to side. This favors the lateral rotation of the 
head in its screw-like descent through the pelvis. At the 
symphysis pubis the depth is 4.4 cm., 1} inch. The 
lateral wall is 9 cm., 3J inches, deep. 

The obturator foramen, situated in the anterior wall of 
the pelvis, is bounded by the bodies and the rami of the 
ischium and pubis. The bony opening is closed by the 
obturator membrane, except at the obturator canal. The 
canal transmits the obturator nerve and vessels. 

Planes of the Pelvis. 

1 . The plane of the brim cuts the ilio-pectineal line and 
the upper margin of the sacrum. In the erect posture of 
the woman the average inclination of the brim to the hori- 
zon is about 60°. 

2. The middle plane cuts the middle of the posterior 



PHYSIOLOGY OF LABOR, 101 

surface of the pubic symphysis and the upper border of 
the third sacral vertebra. 

3. The plane of the outlet cuts the tip of the coccyx, 
the ischial tuberosities and the lower end of the symphy- 
sis pubis. The inclination of the plane of the outlet to 
the horizon is 11°, the summit of the subpubic arch being 
below the level of the tip of the coccyx. 

Practically the plane at which the head escapes from 
the grasp of the bony pelvis is a plane cutting the tip of 
the sacrum and a point just above the lower end of the 
symphysis. 

Pelvic Diameters. Internal Diameters. — (a) At the 
brim : 

1. True conjugate, from the promontory of the sacrum 
to the upper end of the symphysis, more exactly to the 
point at which the symphysis is crossed by the prolon- 
gation of the linea ilio-pectinea. 

2. Diagonal conjugate, from the summit of the subpubic 
arch to the sacral promontory. 

3. Transverse diameter, the greatest transverse diameter 
of the pelvic brim ; it terminates at a point midway be- 
tween the sacro-iliac joint and the ilio-pectineal eminence 
on either side. 

4. Oblique diameters, extending each from one sacro-iliac 
joint, to the opposite ilio-pectineal eminence ; R. O. from 
the right, L. O. from the left sacro-iliac joint. 

(b) At the middle plane : 

1. Antero-posterior diameter, from the upper margin of 
the third sacral vertebra to the middle of the posterior 
surface of the pubis. 

2. Transverse diameter, terminating in points corre- 
sponding to the lower margins of the acetabula. 



102 



ESSENTIALS OF OBSTETRICS. 



3. Oblique diameters, each from the center of one greater 
sacro-sciatic foramen to the center of the obturator mem- 
brane diagonally opposite. 

(c) At the outlet : 

1. Antero-posterior diameter, from the lower end of the 
symphysis pubis to the tip of the coccyx, practically to the 
tip of the sacrum. 

Fig. 28. 




cv. True conjugate, dc. Diagonal conjugate, as. Axis of brim. 
po. Plane of outlet, hh. Line of horizon. 

2. Transverse diameter, the distance between the tubera 
ischiorum, the bisischial diameter. 

3. Oblique diameters, each from the middle of the lower 
edge of the greater sacro-sciatic ligament on one side to the 
point of union between the ischium and pubis on the oppo- 
site side. 

External Diameters. — 1. Externcd conjugate diameter, 
or diameter of Baudelocque, from the depression or fossa 
just below the spinous process of the last lumbar vertebra 



PHYSIOLOGY OF LABOR. 103 

to the most prominent point on the surface overlying the 
upper portion of the pubic symphysis, nearly parallel with 
the internal conjugate. To locate the spine of the last 
lumbar vertebra draw an imaginary line connecting the 
depressions corresponding to the posterior-superior iliac 
spines. The second spinous process above the level of 
this line is that of the last lumbar vertebra. 

2. Ilio-spinal or interspinal diameter, the distance be- 
tween the anterior-superior spines of the ilia measured from 
the outer borders of the sartorius muscles at their origins. 

3. Ilio-cristal or intercristal diameter, in the normal pel- 
vis the greatest transverse width of the pelvis at the crests. 

Approximate Measurements of the Static or Dried Pelvis. 
Internal Diameters. 



ANTEROPOSTERIOR. 


Oblique. 


Transverse. 


Brim, 4 inches. 


4^ inches. 


5 inches. 


Cavity, 4£ " 


4* " 


4J " 


Outlet, 5 ul 


4* " 


4 " 



These values correspond nearly to 10, 11.5 and 12.5 cm. 

At the brim the right oblique diameter is slightly longer 
than the left oblique. The average measurements at the 
brim are more accurately as follows : 

Conjugate. Oblique. Transverse. 

10 cm., 4 in. 12.5 cm., 5 in. 13.5 cm., 5j in. 

The circumference of the brim is about 40 cm., 16 in.; 

of the outlet, 33 cm., 13 in. 

Approximate Measurements of the Dynamic Pelvis. 

Internal Diameters. 

The internal diameters are all reduced 6 mm., J in., by 

the presence of the soft structures in the dynamic pelvis. 

1 Distance from lower end of symphysis pubis to tip of sacrum 12.5 
cm., 5 in.; to tip of coccyx, 9.5 cm., 3| in.; when coccyx is pushed 
back, 11.5 cm., 4 J in. 



104 ESSENTIALS OF OBSTETRICS. 

The transverse diameter at the brim is still more dimin- 
ished by the psoas and iliacus muscles, so much so that 
the oblique is the longest diameter in the dynamic pelvis. 

External Diameters. 

External conjugate 20 cm., 8 inches. 

Interspinal 25.5 " 10 " 

Intercristal 28 " 11 " 

To estimate the iuternal conjugate from the external 
deduct 7 to 12.5 cm., 2} to 5 inches, according to 
the estimated thickness of the overlying bony and soft 
parts. 

The average external circumference of the pelvis meas- 
ured over the symphysis and on a line running just below 
the iliac crests and across the middle of the sacrum is 
nearly 1 meter (little more than one yard). 

Difference between the Male and the Female Pelvis. 

Distinguishing Marks of the Female Pelvis. 

As a Whole. — The greater pelvis is wider ; the lesser 
pelvis is larger in all its diameters and of shallower depth. 
The bones are lighter and are more slender. The inclina- 
tion of the pelvis is greater. 

The Brim. — The shape is less triangular. The sacro- 
vertebral angle is more pronounced and more prominent. 
The pubic spines are more widely separated. 

The Cavity is not so funnel-shaped. The sacrum is 
shorter and broader and more strongly curved. 

The Outlet. — The subpubic angle is greater — 90°, the 
angle in the male being 70°. The depth of the sym- 
physis pubis is little more than half that in the male. 



PHYSIOLOGY OF LABOR. 105 

Obstetric Anatomy of the Pelvic Soft Parts. 
The transverse diameter of the brim is somewhat dimin- 
ished by the iliacus and psoas muscles. They encroach 

Fig. 29. 




Male pelvis. 

upon the lateral margins of the inlet to the extent of a 
quarter of an inch or more on each side. The external 
iliac vessels run along the inner borders of these muscles. 

Fig. 30. 




106 ESSENTIALS OF OBSTETRICS. 

In the cavity no muscular structures overlie the median 
portion of either the anterior or posterior pelvic wall. On 
either side of the median section are the pyriformis muscle 
posteriorly and the obturator internus anteriorly and later- 
ally, too thin to affect the pelvic diameters. 

The pyriformis arises by a series of digitations from the 
lateral aspects of the sacrum anteriorly and from the upper 
portion of the sacro-sciatic ligament, and its fasciculi 
converge to pass out through the greater sacro-sciatic 
foramen. 

The obturator internus arises from the circumference of 
the obturator foramen and the inner surface of the obturator 
membrane ; its fibers converge to a tendon which passes 
through the lesser sacro-sciatic foramen. 

The outlet of the pelvis is closed by the pelvic floor or 
diaphragm, which is made up chiefly of muscles and fasciae. 

The Pelvic Floor. — The upper aspect of the pelvic 
floor is concave ; its lower, convex from before backward. 

It is limited above by the peritoneum, except where that 
structure is lifted to be reflected over the pelvic viscera and 
their appendages. Its inferior surface is skin. 

Its median portion is obliquely traversed by three mus- 
cular slits, the urethra, the vagina, the rectum. These 
canals are approximately parallel with the plane of the 
pelvic brim, except that the end of the rectum turns back- 
ward nearly at a right angle with the vagina. 

The posterior vaginal wall and the soft structures behind 
it make the sacral segment of the pelvic floor ; the anterior 
wall of the vagina and the soft parts in front of it constitute 
the pubic segment of the pelvic floor. (Hart.) 

Measurements. — Coccyx to anus, in the nullipara, 4.5 
cm., If in.; anus to lower edge of vulvar orifice, in the 



PHYSIOLOGY OF LABOR. 107 

nullipara, 3.1 cm., 1\ in.; in the parous woman, 2.5 cm., 
1 in.; in the primigravida at term, 3.8 cm., 1J in. 

Greatest transverse width on the bisischial line, *1 0.7 
cm., 4 J in. Perpendicular thickness of the pelvic floor 
at the anus, 5 cm., 2 in. 

In the nullipara the average projection of the pelvic 
floor below a line drawn from the tip of the coccyx to the 
lower end of the symphysis is 2.5 cm., 1 in.; in the parous 
woman at term, 9.5 cm., 3| in. 

The length of the sacral segment during labor at the 
moment of expulsion, coccyx to lower edge of the vulvar 
orifice, is 15 to 17.5 cm., 6 to 7 in. 

Principal Component Structures. 

Fascial Sheets of the Pelvic Floor. — The most im- 
portant supporting structures of the pelvic floor are its 
fascial sheets. Upon these the strength of the pelvic 
diaphragm almost wholly depends. 

Recto-vesical or Visceral Fascia. — It will be remembered 
that the parietal fascia of the lesser pelvis is continuous 
with the iliac fascia and covers the obturator and the 
pyriformis muscles. From this is given off a transverse 
layer which stretches across the pelvis. This is the recto- 
vesical fascia. Its line of attachment to the parietal fascia 
is the white line, or arcus tendineus. The white line ex- 
tends from- the ischial spine to the posterior aspect of the 
body of the pubis, arching downward. Its greatest dis- 
tance below the ilio-pectineal line is about 5 cm., 2 in. 

At the lateral walls of the bladder, the vagina and the 
rectum, this fascia divides into four layers (Webster) : 

1. Vesical Layer. — This layer runs upward on each 
lateral aspect of the bladder to form the lateral true liga- 
ments of the bladder. 



108 ESSENTIALS OF OBSTETRICS. 

2. Vesico-vaginal Layer. — This layer runs between the 
bladder and the anterior vaginal wall. 

3. ' Recto-vaginal Layer. — This layer extends between 
the lower portion of the vagina and the rectum, blending 
below with the connective tissue of the perineal body. 

4. Rectal Layer. — This layer envelops the lower end of 
the rectum posteriorly, being closely attached to its poste- 
rior wall. 

The anal fascia covers the inferior surface of the levator 
ani muscles, presently to be described. 

The Triangular Ligament. — Across the triangular space 
between the ischio-pubic rami and in front of the bis- 
ischial line are stretched the two fascial sheets which con- 
stitute the triangular ligament. The deep layer of the 
triangular ligament blends with the parietal fascia and is 
in contact with the inferior surface of levator ani muscle, 
fusing with its fascial sheath. The two layers blend at 
the bisischial line with each other and with the super- 
ficial fascia. The union of these layers at the bisischial 
line forms the perineal ledge or ischio-perineal ligament. 
These three sheets are sometimes described as the deep, 
the middle and the superficial layers of the perineal 
fascia. They are perforated by the urethra and the va- 
gina. Between the middle and the superficial layers 
of the perineal fascia are the superficial transversus peri- 
nei, the bulbo-cavernosus and the ischio-cavernosus mus- 
cles, on either side. 

Muscles of the Pelvic Floor. 
Levator Ani. — The anatomy of this muscle, according to 
Browning, who was the first to describe it correctly, is as 
follows : 



PHYSIOLOGY OF LABOR. 109 

It immediately underlies the recto-vesical fascia. It 
consists of three parts. The first takes its origin from 
the posterior surface of the os pubis and from the deep 
layer of the triangular ligament ; the second from the 
white line ; the third from the ischial spine. The bony 
origin of the pubic bundle is about 12 mm., \ inch, 
from the symphysis and 3.5 cm., \\ inch, below the 
upper border of the bone. The entire pubic bundle 
is about 12 mm., \ inch, wide and 3 mm., \ inch, 
thick at a point just beyond its origin. Its course is 
nearly horizontally backward. Its superficial fibers 
blend with those of the external sphincter ani. Of the 
deeper fibers a few turn forward into the perineal body. 
The greater number take a backward course toward 
the coccyx, to which most of them can be traced. Some 
of the fibers in their course toward the coccyx lie in 
close proximity to the median line, but none are con- 
tinuous with their fellows of the opposite side. The 
pubic bundle as it sweeps by the vagina is 5 mm., \ inch, 
away from it. 

The part of the muscle which arises from the white line 
is thin and membranous and is weakly attached to it. The 
direction of its fibers is at first downward, inward and back- 
ward toward the rectum and the rectococcygeal raphe. 
They all fall short of the rectum and the raph£, turning 
toward the coccyx, most of them reaching it, some first 
becoming aponeurotic. 

The part of the levator which springs from the ischial 
spine forms a small spindle-shaped bundle. Its course is 
nearly transverse. The most of its fibers are inserted into 
the tip of the coccyx ; a few turn forward upon the recto- 
coccygeal raphe. 



110 



ESSENTIALS OF OBSTETRICS. 



Nowhere do the fibers of the levator cross the median 
line to join those of its fellow on the opposite side. 

The anal fascia on the lower and a very thin fascial 
layer on the upper surface of the levator constitute its 
sheath. These are separable from the contiguous fascial 
sheets previously described. 

Superficial Transversus Perinei. — Origin, the inner aspect 

Fig. 31. 




Axes of the pelvis. A. Axis of superior plane. B. Axis of mid-plane. C. Axis 
of inferior plane. D. Axis of canal. E. Horizon. (Playfair. ) 



of the tuberosity and ramus of the ischium ; insertion, the 
center of the perineal body. 

The deep transversus perinei lies between the deep and the 
middle layers of the perineal fascia. It takes origin from 
the descending ramus of the pubis, and is inserted into its 
companion muscle. 



PHYSIOLOGY OF LA BOB. Ill 

Buibo-cavernosus. — Origin, the external sphincter ani 
and the perineal fascia at one side of it: insertion, by 
three slips, one into the posterior surface of the bulb, one 
into the lower aspect of the clitoris and one into the 
vestibular mucous membrane. 

Ischio-cavernosus. — Origin, the tuberosity of the ischium 
and ischio-pubic ramus; insertion, the crus clitoridis and 
an aponeurosis covering the posterior part of the body of 
the clitoris. 

The sphincter ani externus is made up of two semilunar 
bands, each about 3 cm., J inch, wide, one on either side 
of the anus. Origin, the tip of the coccyx and the skin 
adjacent thereto; insertion, the tendinous center of the 
perineal body. 

The perineal body, so called, is the body of elastic and 
muscular tissue between the lower end of the rectum and 
the vagina. Its height is 3.7 cm., 1J inch, its transverse 
width 3.7 cm., 1J inch, and the length of its base antero- 
posteriorly 3.1 cm., 1J inch, in the nullipara. 

The Parturient Axis. 

The axis of the brim is a line perpendicular to the plane 
of the inlet at its central point; its prolongation passes 
through the umbilicus and the tip of the coccyx. It is 
coincident with the axis of the uterus at term. 

The axis of the outlet is the perpendicular to the plane 
of the outlet at its midpoint. Prolonged it cuts the lower 
border of the first piece of the sacrum. 

The axis of the outlet of the soft parts, the line of expul- 
sion, looks almost directly forward. 

The parturient axis is made up of the axes of the sev- 
eral planes of the birth-canal. It is an irregular parabola. 



112 ESSENTIALS OF OBSTETRICS. 

3. The Passenger. 
Obstetric Anatomy of the Foetal Head. 

For the obstetrician the foetal head presents two divi- 
sions : (1) The cranial vault. (2) The cranial base and 
face. The former, owing to the semi-cartilaginous char- 
acter of its bones and to their mobility, is plastic, a fact of 
importance in facilitating the passage of the head through 
the pelvis ; the latter is unyielding, its bony structures being 
more highly ossified and more firmly united. Protection 
is thus afforded during labor to the vulnerable structures 
at the base of the brain. It is with the cranial vault that 
obstetric problems have mainly to do. 

The cranial vault comprises the parietal, the frontal and 
the squamous portions of the occipital and the temporal 
bones. 

The cranial base is composed of the basilar portion of 
the occipital bone, the petrous portion of the temporal 
bones and of the entire sphenoid and ethmoid bones. 

The Sutures. — The sutures are the membranous inter- 
spaces between two adjacent cranial bones. Of special ob- 
stetric importance are the following : 

The sagittal or inter-parietal suture ; 
The frontal or inter-frontal suture ; 
The coronal or fronto-parietal suture ; 
The lambdoidal or occipitoparietal suture. 

The Fontanelles. — The fontanelles are the membranous 
spaces between the angles of three or four adjacent bones of 
the cranium. The fontanelles of obstetric interest are two, 
the anterior and the posterior. 

Hie anterior or large fontanelle or bregma is situated 
at the anterior end of the sagittal suture. In the vaginal 



PHYSIOLOGY OF LABOR. 113 

examination during labor it is identified by the following 
characters : 

(1) It is kite-shaped or quadrangular, its most acute angle 
looking forward ; (2) its average diameter is 2.5 cm., 1 in.; 
(3) four sutures run into it. 

The posterior fontanelle lies at the posterior end of the 
sagittal suture. To the examining finger it presents the 
following distinguishing marks : 

(1) It is triangular; (2) it is small, usually a mere depres- 
sion scarcely perceptible to the finger-tip ; (3) three sutures 
run into it ; (4) immediately behind it is the squamous or 
triangular portion of the occipital bone which is hinged to 
the basilar portion by a movable joint of fibrous tissue. 

Protuberances. — The foetal head presents five pro- 
tuberances which are of interest as obstetric landmarks 
viz., one occipital, two parietal and two frontal. 

The occipital protuberance is situated on the occipital 
bone an inch or more behind the posterior fontanelle. 

The parietal protuberance or boss on either side of the 
cranium is the eminence at the center of the parietal bone. 

The frontal protuberance is the prominence at the cen- 
tral portion of each frontal bone. 

The Vertex.^The vertex is that part of the cranial 
vault lying between the fontanelles and extending laterally 
to the parietal eminences. 

The Occiput. — The occiput is the portion of the cranium 
behind the posterior fontanelle. 

The Sinciput. — The sinciput is that portion of the 
cranial vault lying in front of the bregma. 

Measurements of the Foetal Head. 
The biparietal diameter is the greatest transverse width 



114 ESSENTIALS OF OBSTETRICS. 

of the head measured through the parietal emineuces ; its 
value is 9.5 cm., 3| inches. 

The fronto-mental diameter extends from the summit of 
the forehead to the center of the lower margin of the chin. 
Its value is 9 cm., 3 J inches. 

The trachelo-bregmatic diameter is measured from the 



Fig 




Foetal head viewed from behind. PP. Biparietal diameter. (After Fakabeuf.) 

neck just above the larynx to the center of the bregma ; 
its value is 9.5 cm., 3{ inches. 

The occipitofrontal diameter is the distance from the tip 
of the occipital protuberance to the root of the nose ; its 
value is 11.5 cm., 4 J inches. 

The occipito-mental diameter is measured from the sum- 
mit of the occipital protuberance to the center of the lower 
margin of the chin ; its value is 14 cm., 5 J inches. 

The suboccipito-bregmatic diameter is the distance from 



PHYSIOLOGY OF LABOR. 



115 



the junction of the nucha and the occiput to the center of 
the bregma; its value is 9.5 cm., 3j inches. 

The bitemporal diameter is the transverse diameter of 
the head between the lower extremities of the coronal 
suture; its value is 8 cm., 3 J- inches. 

The bimastoid diameter is the greatest distance between 
the mastoid apophyses ; its value is 7 cm., 2f inches. 

Circumference. — The subocci pito-bregmatic circumfer- 
ence is measured over the junction of the nucha and 



Fig. 33. 




Ftetal head viewed from the side. OF. Occipitofrontal diameter. OB. Sub- 
occipito-bregmatic diameter. TB. Trachelo-bregmatic diameter. (After Fara - 

BEUF.) 

occiput _and over the center of the bregma ; its value is 
about 33 cm., 13 inches, in male, 1.2 cm., J inch, less in 
female heads. 

It will be seen that the principal diameters of the foetal 



116 ESSENTIALS OF OBSTETRICS. 

head, namely, the biparietal, the occipito-fro-ntal and the 
occipito-mental, are approximately 3J, 1 4J, 5J inches re- 
spectively. The fronto-mental diameter, too, is 3 J inches. 

Trunk Diameters. 
The bisacromial diameter is 12 cm., 4f inches. The 
bitrochanteric is 8.8 cm., 3 J inches. The trunk diam- 
eters are much more compressible than are the cephalic. 

Presentation, Position and Posture of the Foetus. 

Presentation. Definition. — By presentation is meant 
the relation of the long axis of the foetal ovoid to the 
uterine axis. 

Varieties : 

1. Longitudinal. 

A. Cephalic, 

a. Vertex ; 

b. Face; 

c. Brow. 

B. Pelvic, 

a. Breech ; 

b. Feet. 

2. Transverse. 

a. Shoulder ; 

b. Arm ; 

c. Hand. 

The presenting part is that part of the foetal ovoid which 
offers to the examining finger within the girdle of resistance. 

Relative Frequency of Presentations. — In at least 96 per 

cent, of all term labors the foetus presents by the cephalic 

extremity. Breech or pelvic presentation occurs in 3 per 

cent, of term births, lateral in about 1 per cent. The face 

1 More exactly 3| inches. 



PHYSIOLOGY OF LABOR. 117 

or brow is the presenting part in a little less than -f^ per 
cent, of cephalic births. The preponderance of cephalic 
presentation is mainly clue to adaptation ; the foetal mass 
tends to accommodate its position to the shape of the uterus. 
Position. — Position is the relation of the presenting part 
to the quadrants of the pelvic brim. These quadrants are 
the left anterior, the right anterior, the right posterior and 
the left posterior quadrant of the brim. The positions 
are named according to the particular quadrant which the 
leading anatomical landmark on the presenting part con- 
fronts. For each presenting part there are, therefore, four 
possible positions. 

Vertex positions are named according to the quadrant 
which the occiput confronts. When the occiput looks 
toward the left anterior quadrant the position is left 
occipito-anterior ; when toward the right anterior quad- 
rant the position is right occipito-anterior and so on. 

Face positions are named in like manner, according to 
the direction of the chin ; breech positions with reference 
to the direction of the sacrum, and shoulder positions to 
that of the scapula. 

Thus Ave have the following positions : 
Vertex Positions. 

Left occipito-anterior — L. O. A. 
Right occipito-anterior — R. O. A. 
Right occipito-posterior — R. O. P. 
Left occipito-posterior — L. O. P. 
Relative frequency: 70, 10, 17, and 3 per cent, respec- 
tively. 

Face Positions. 

Left mento-anterior — L. M. A. 
Right mento-anterior — R. M. A. 



118 ESSENTIALS OF OBSTETRICS. 

Right mentoposterior — R. M. P. 
Left mento-posterior — L. M. P. 
Breech Positions. 

Left sacro-anterior — L. S. A. 
Right sacro-anterior — R. S. A. 
Right sacro-posterior — R. S. P. 
Left sacro-posterior — L. S. P. 
Transverse or Shoulder Positions. 

Left scapuloanterior — L. Sc. A. 
Left scapuloposterior — L. Sc. P. 
Right scapulo-posterior — R. Sc. P. 
Right scapuloanterior — R. Sc. A. 
Note that in shoulder as in other presentations the terms 
right and left refer to the mother. 

Posture. — By posture is meant the relation of the foetal 
members to one another. The usual foetal posture during 
pregnancy and parturition is one of flexion. As an element 
in the labor posture is most important as relates to the head. 

II. CLINICAL COURSE AND MECHANISM OF NORMAL 
LABOR. 

Normal labor, as we shall define it, includes only labors 
in which all the mechanical factors are normal and which 
are otherwise uncomplicated — labors, in other words, hav- 
ing no element of dystocia. Only vertex births in an- 
terior positions will be classed as normal. 

Stages of Labor. 

The first stage, or stage of dilatation, ends with the com- 
plete dilatation or canalization of the utero-cervical zone. 

The second stage, or stage of expulsion, ends at the birth 
of the child. 



PHYSIOLOGY OF LABOR. 119 

The third, or placental stage, includes the expulsion of 
the placenta, the complete evacuation and persistent re- 
traction of the uterus. 

Causes of the Onset of Labor. 
The causes which determine the advent of labor are not 
definitely known. Probable causes are : The loosening 
attachment of the ovum in the later weeks of gestation; 
distention of the uterus and the consequent reaction of the 
uterine muscles; development of the contractile power of 
the uterus ; the growing vigor of the foetal movements ; 
excess of carbon dioxide in the blood, acting upon the 
motor centers ; increasing irritability of the uterus ; the in- 
fluence of the menstrual molimen. The separation of the 
decidua begins at the lower uterine segment with the first 
labor pains. The ovum thus becomes in part a foreign 
body. This furnishes sufficient stimulus for continued 
expulsive efforts. 

Phenomena of Beginning Labor. 
Signs of the onset of labor are : 
Lightening ; 

Irritability of the bladder and rectum ; 
Increased flow of vaginal and cervical secretion ; 
The show, a bloody discharge from the vagina ; 
Expulsion of the cervical mucous plug ; 
Rhythmic uterine pains. 
By lightening is meant the sinking of the uterus, which 
takes place usually within from ten to fourteen days before 
labor actively begins. The uterus sinks more deeply in 
the pelvis. The waist-line becomes smaller. As the uterus 
settles lower in the pelvis the pressure on the bladder and 



120 ESSENTIALS OF OBSTETRICS. 

rectum is increased and these viscera are evacuated 
oftener than is the usual habit. Lightening, however, 
is not observed in all cases. 

At the onset of active labor urination and defecation 
become still more frequent and there is a profuse secre- 
tion of vaginal and cervical mucus. The vaginal discharge 
may be stained with blood — the show. Usually the mu- 
cous plug which blocks the cervix during pregnancy is ex- 
pelled as a tenacious, jelly-like mass. 

The most reliable evidences of beginning labor are the 
occurrence of rhythmic uterine pains and contraction of 
the uterus with each pain as felt by the examining hand 
held upon the abdomen. The first pains are often little 
more than a sense of pressure, and are felt in the lumbo- 
sacral region. As labor advances they become more pro- 
nounced, extend in front to the lower abdominal region 
and radiate down the thighs. 

Labor Pains. — Labor pains are the painful uterine con- 
tractions of labor. The painful character of the contrac- 
tions is due to pressure on the nerve-filaments of the 
uterus and on the nerve-trnnks in the pelvic cavity. 

The duration of a pain is thirty to sixty seconds. 

The usual intervals between the contractions at the be- 
ginning of labor are twenty to thirty minutes. They 
gradually shorten as labor goes on and may be reduced to 
a fraction of a minute at the acme of expulsion. 

The intensity progressively increases, reaching its maxi- 
mum at the expulsion of the head from the vaginal outlet. 

1. First Stage: Stage of Dilatation. 
Dilatation. — Three agencies are concerned in dilatation 
of the cervix : 



PHYSIOLOGY OF LABOR. 121 

1. Traction of the longitudinal muscular fibers of the 
upper uterine segment ; 

2. Hydrostatic pressure of the bag of waters ; 

3. Softening of the cervical structures by serous infil- 
tration. 

Action of the Longitudinal Muscular Fibers. — The trac- 
tion of the upper segment of the uterus draws the lower 
segment upward over the presenting portion of the ovum. 
The dilatation begins at the os internum. With the first 
active labor pains the ovum is partially detached from 
the lower uterine segment. The internal os expands and 
the bag of waters protrudes into the cervical zone with 
each pain, receding in the intervals. At first the cervix, 
becoming somewhat funnel-shaped during the pains, nearly 
regains its cylindrical form in the intervals. As the labor 
advances the os internum is permanently effaced and the 
ovum rests against the os externum. From this time the 
progress of canalization is indicated by the size of the 
external os. 

The bag of waters is the portion of the membranes which 
in the course of the labor protrudes downward into the 
cervix. It plays an important part in the mechanism of 
dilatation. Its contained liquor amnii, the fore- waters, is 
partly cut off from that above the head, the hind-waters, 
by the ball-valve action of the head as the latter is driven 
into the lower uterine segment during a pain. The general 
uterine pressure, however, is transmitted in some measure 
to the fore-waters. In accordance with the law of hydro- 
statics the bag of waters is not only urged downward, but 
it exerts a certain amount of expansive force upon the 
walls of the passive cervical zone. 

When the membranes rupture prematurely the dilatation 



122 ESSENTIALS OF OBSTETRICS. 

of the cervix usually goes on more slowly and is more 
painful. The foetal head is not so good a dilator as the 
fluid wedge, the bag of membranes. It lacks the active 
dilating power and the equable pressure of the bag of 

Fig. 34. 




The uterus after complete canalizatiou of the utero-eervical zone. CR. Contraction 
ring or retraction ring. oi. Os internum, oe. Os externum. 

waters. The mechanical disadvantage is still greater in mal- 
presentations and malpositions, by reason of the greater in- 
equality of pressure on different parts of the resisting girdle. 
In vertex presentation the bag of waters has a watch- 
glass shape. 



PHYSIOLOGY OF LABOR. 123 

The membranes rupture usually by the time they reach 
the pelvic floor, often sooner, or only on interference. 

Softening of the cervix, established before labor, is much 
increased in course of the first stage. During a pain the 
walls of the uterus are everywhere compressed by contrac- 
tion upon its contents, except at the cervix. The blood 
vessels of the cervix, unsupported by pressure, become 
engorged, and a serous transudation takes place into its 
tissues, loosening its structure. 

Retraction Ring. — In course of the first stage of labor 
the upper uterine segment becomes thickened, retraction 
of the muscular structures into that segment taking place 
with each pain ; the lower segment becomes correspond- 
ingly thinned. The line of demarcation between the thick- 
ened upper and the thinned lower segment is the con- 
traction ring, or, as it may more properly be termed, the 
retraction ring. It is well defined only during a pain. The 
retraction ring generally can be felt above the brim by the 
close of the first stage, and it rises higher in proportion to 
the number and strength of the pains. 

Retraction of the Pubic Segment. — The posterior wall 
of the bladder and the whole pubic segment of the 
pelvic floor begin to be drawn upward during the latter 
part of the stage of dilatation. The elevation is marked 
during the second stage. The bladder is thus lifted partly 
out of the lesser pelvis away from injurious pressure dur- 
ing the birth. Only a very small portion of the organ 
rises above the level of the pubic bones. The length of 
the urethra remains unchanged. 

The duration of the first stage is from two or three 
hours to several days. The average length of this stage 
is, in primiparse, eleven hours ; in multipara?, seven hours. 



124 ESSENTIALS OF OBSTETRICS. 

2. Second Stage : Stage of Expulsion. 

The Mechanism of the Second Stage of Labor. — The 
most important mechanical phenomena of the second 
stage of labor are those pertaining to the series of passive 
movements which the foetus undergoes in course of its 
expulsion through the birth canal. 

The engaging diameters of the head being larger than 
those of any other part of the foetal mass, the essential 
mechanical phenomena of the stage of expulsion are 
those pertaining to the birth of the head. To rightly 
comprehend them it must be borne in mind that the foetal 
head is an irregular ovoid body, which in typical labors 
tightly fits the birth canal ; and that the shape and direc- 
tion of the parturient tract change at every point through- 
out its length. The essential cause of the head move- 
ments is adaptation or accommodation of the head to the 
varying shape and course of the birth-canal. These move- 
ments are descent, flexion, rotation, extension ; restitution 
and external rotation are additional movements impressed 
upon the head after its escape from the passages, in con- 
sequence of the spiral motion of the trunk in course of its 
descent as explained later.. 

Descent. — In the stage of expulsion the uterine contrac- 
tions are reinforced by the action of the abdominal 
muscles. Hence the bearing-down character of the pains 
at this period. Before escape of the waters the expellant 
force is transmitted to the head through the entire uterine 
contents. After rupture of the membranes the propel- 
ling force acts directly upon the foetus. The fcetal mass 
under the general uterine pressure moves in the direction 
of least resistance, through the birth-canal. 



PHYSIOLOGY OF LABOR. 125 

The head advances with the pains and recedes in the 
intervals, and in normal conditions this advance and re- 
cession continue till the head is well in the grasp of the 
vulvar ring. 

Flexion. — A certain degree of flexion is present pri- 
marily. It belongs to the normal posture of the foetus in 
utero. 

The primary flexion is increased as the descent be- 
gins, and for this reason : The head is so hinged upon 
the trunk that the occipito-frontal diameter corresponds 
to a lever of unequal arms, the frontal arm being the 
longer. On engagement in the utero-cervical zone, the 
resistance, though equal at the two ends of the lever, acts 
with greater effect on the longer or frontal arm, and the 
chin dips toward the sternum. Flexion is still more in- 
creased when the head encounters the greater resistance 
of the bony canal. 

Another agency in flexion is the influence of the 
uterine contractions which tend to bring the long diameter 
of the cephalic ellipsoid into conformity with the long 
diameter of the uterus. 

The advantage of flexion is apparent. It substitutes 
the suboccipito-bregmatic diameter, 9.5 cm., 3} inches, for 
the occipito-frontal, 11.5 cm., 4 J inches, a gain quite 
enough in most cases to make all the difference between a 
possible and an impossible delivery. The head undergoes 
still further accommodation to the passages by moulding 
vet to be described. 

Rotation. — At the brim the longest diameter of the pel- 
vis which is available for the passage of the head is the 
oblique ; at the outlet the longest is the antero-pos- 
terior. The head, therefore, as it descends must rotate 



126 ESSENTIALS OF OBSTETRICS. 

about the axis of the birth-canal to keep its longest en- 
gaging diameter constantly in the longest diameter of the 
pelvis during its passage through it. 

Rotation of the head is due chiefly to the slope of the 
lateral halves of the pelvic floor downward, forward and 
inward. In normal labor the occipital pole first lands 
upon one lateral half of the floor, and as it descends it is 
thrust forward and inward beneath the pubic arch. A 
firm pelvic floor, together with efficient labor pains, is, 
therefore, essential to forward rotation of the occiput. 
Flexion, moulding of the head and the development of the 
caput succedaneum, yet to be described, promote rotation 
by increasing the dip of the occipital pole. After the 
occiput has sunk below the level of the pubic arch its 
forward rotation is due partly to the fact that this is the 
direction of least resistance. Complete rotation is seldom 
observed. The head is usually expelled in a position 
slightly oblique to the median antero-posterior plane of 
the parturient outlet. 

Extension. — After the occiput has escaped beneath the 
pubic arch the nape of the neck rests against the subpubic 
ligament, and the head, rotating upon the nucha as a 
pivotal point, is born by a movement of extension, the 
vertex, the forehead and the face successively sweep- 
ing over the perineum. The chin, however, does not, as 
formerly assumed, leave the sternum till the moment of 
expulsion. A brief pause usually follows the birth of the 
head. 

Restitution. — Since the shoulders descend in the oblique 
diameter opposite that in which the head engages, rotation 
of the head during its descent through the pelvis brings 
about a certain degree of torsion of the neck. After the 



PHYSIOLOGY OF LABOR. 127 

head is born the neck untwists and the head, if left to 
itself, takes a position corresponding to that in which it 
entered the pelvis. This movement is termed restitution. 
It may be utilized as a means of confirming the diagnosis 
of position. 

External rotation is a still further rotation of the head 
which is observed during the expulsion of the body ; it 
occurs in consequence of the spiral movement of the trunk 
as it traverses the birth-canal. 

Birth of the Trunk. — The shoulders and the breech rotate 
to some extent as they descend through the pelvis, but less 
perfectly than the head. The rotation takes place in a 
direction opposite to that of the head, since the shoulders 
and breech come down in the opposite oblique diameter of 
the pelvis. The anterior shoulder is expelled first, or it 
lodges behind the pubic bones and the posterior shoulder 
first appears at the ostium vaginae and escapes over the 
edge of the vulvar ring. A gush of bloody water gen- 
erally accompanies the birth of the trunk. 

Other Phenomena : Caput Succedaneum. — The caput suc- 
cedaneum is an cedematous swelling developed upon the 
presenting part of the foetus after rupture of the mem- 
branes. In cephalic presentation it forms on the part of 
the head within the girdle of resistance. The vessels 
here, unsupported by pressure during the uterine contrac- 
tions, become engorged and serous infiltration of the tis- 
sues ensues. The size of the tumor increases with the 
number and strength of the pains. Its location differs 
with the position in which the head has entered the pelvis. 
In L. O. A. positions it forms on the right, in R. O. A. 
upon the left, posterior parietal region. In R. O. P. posi- 
tions it appears upon the left anterior, and in L. O. P. 



128 ESSENTIALS OF OBSTETRICS. 

upon the right anterior, parietal region. The location, 
however, may be modified when the head has rested long 
in the lower portion of the birth -canal after having under- 
gone partial rotation. 

Moulding of the Head. — Owing to the plasticity of the 
cranial vault the adaptation of head to pelvis is in part 
accomplished by moulding. Under pressure of the pelvic 
walls the engaging diameters of the cranial vault are re- 
duced and the head is elongated in the direction of the 
passages. 

Perineal Stage. — As the occiput approaches the outlet 
of the soft parts the sacral segment of the pelvic floor is 
stretched and pushed downward and forward in front of 
the advancing head. Its length from coccyx to posterior 
commissure is increased at the moment of expulsion to 13 
cm., 5 or 6 inches. The sphincter ani is relaxed, the anal 
orifice gapes widely and feces are usually expelled from 
the rectum as the head passes over the pelvic floor. As 
the equator of the head escapes from the vulvo-vaginal 
orifice the posterior segment of the floor promptly retracts 
over the face. 

Pulse and Temperature. — The maternal pulse-rate is 
somewhat accelerated during the pains. The maternal 
temperature, particularly in hard labor, is generally a 
degree or more above the normal at the termination of the 
birth. 

The foetal pulse-rate is retarded at the height of the 
pains, owing to increased arterial tension in the foetus. 

The length of the second stage in priniiparse is from 
one to seven hours — average about two hours ; in 
multipara?, fifteen minutes to two hours — average about 
one hour. 



PHYSIOLOGY OF LAB OB. 129 

3. Third Stage: Placental Stage. 

Events. — (1) Separation of the placenta ; (2) expul- 
sion of the placenta and blood-clots ; (3) retraction of the 
uterus. 

Separation of the placenta takes place iu the meshy layer 
of the decidua; it is brought about partly by contraction 
of the placental site which goes on as the uterus retracts, 
and partly by the extruding force of the uterine con- 
tractions. 

Expulsion of the placenta is effected by the extruding 
force of the uterine contractions. The after-birth may 
present by its amniotic surface or may be expelled edge 
first. Its expulsion from the vagina is explained by the 
tonicity of the muscular structures in the posterior seg- 
ment of the pelvic floor. The placenta expelled through 
the rent in the membranes, through which the child has 
already escaped, drags the membranes after it, gradually 
peeling them from the uterine wall. 

Retraction of the uterus consists in a thickening and 
shortening of its wall, due in part to rearrangement of 
the muscular fibers, in part to thickening and shortening 
of the fibers themselves. Normally retraction of the 
upper segment is promptly established at the close of 
labor. It securely ligates the uterine vessels which have 
been torn across by separation of the placenta. The 
lower segment remains passive for several hours after the 
close of labor. 

The duration of the third stage varies from a few min- 
utes to two hours. Its average length is from twenty to 
thirty minutes. 

The average length of normal labor is, in prirniparse, 
9 



130 ESSENTIALS OF OBSTETRICS. 

twelve hours ; in multipara, eight hours. Variations from 
two to twenty-four hours are not uncommon within normal 
limits. 

III. MANAGEMENT OF LABOR. 

Preparatory. — The duties of the obstetrician to his 
patient, especially in the later months of pregnancy, are 
scarcely less important than those pertaining to the man- 
agement of labor and the post-partum period. The en- 
forcement of hygienic rules, attention to the general health, 
urinary examinations once weekly or oftener during the 
last two or three months and instructions with reference 
to the care of the nipples are essential to the proper con- 
duct of the obstetric case. At this period, too, the physi- 
cian acquaints himself in so far as possible with the con- 
ditions with which he will have to deal in the subsequent 
care of the patient. A month before the expected date of 
labor a systematic examination should be made according 
to the following plan : 

Ante-partum Examination. 

Scheme. 
History. 

General health ; 

Character of previous pregnancies, labors, puerperi- 
ums, miscarriages ; 

Date of last menses and probable date of labor ; 

Important data concerning the present pregnancy ; 

Character of the vaginal discharge. 
Breasts. 

Shape ; 

Development ; 

Nipples, development, malformations. 



PHYSIOLOGY OF LABOR. 131 

Abdominal Examination. 
Pendulous abdomen ; 
Hydramnios ; 
Complicating tumors ; 
Twins ; 

Location of placenta ; l 

Presentation, position and posture of foetus ; 
Length of the foetal ovoid ; 
Size and hardness of the foetal head ; 
Foetal pulse-rate ; 

External measurements of the pelvis in primiparse 
and in multipara? with a history of difficult labors. 

Vaginal Examination. 

Former injuries — pudendal, vaginal, cervical ; 

Placenta prsevia ; 

Obstructing tumors ; 

Measurements of the diagonal conjugate and other 
diameters of the pelvis in primiparse and in mul- 
tipara whose history excites suspicion of pelvic 
contraction. 

Method of Abdominal Examination for Presentation and 
Position. 

1. Preparation. — The patient is placed in the horizontal 
posture (supine, with the lower limbs extended) with the 
abdomen fully exposed, or covered only with a sheet. 
When the sheet is used the examination may be conducted 
through this covering, or, better, with the hands under- 
neath it. Before examining, the hands of the operator are 

1 When the round ligaments are far apart, converging downward, the 
placenta is on the anterior wall ; when they fall near together, con- 
verging upward, it is on the posterior wall of the uterus. For diag- 
nosis of vicious implantatiou of placenta see Placenta Prsevia. 



132 



ESSENTIALS OF OBSTETRICS. 



bathed in warm Avater to render the sense of touch more 
acute, and because contact of cold hands might excite re- 

Fig. 35. 




Displacing foetus to 



3 side of abdomen for locating dorsal plane. 



flex contractions of the abdominal and uterine muscles 
which would interfere with the examination. 



PHYSIOLOGY OF LABOR. 133 

2. Locating the dorsal plane and small parts. 

This is done by any one or all the following methods : 

a. The entire surface of the abdomen is palpated 
systematically, using light touches with the palmar 
surfaces of the finger-tips. 

b. Downward pressure is applied with one hand on 
the upper foetal pole in the direction of the foetal 
axis ; this steadies the dorsum and brings it nearer 
to the abdominal wall where it may more satis- 
factorily be palpated with the other hand. The 
child's back is identified by the length and breadth 
of the resisting plane. Distinguish from the 
lateral plane by the greater width of the dorsal, 
by the convexity of the latter and by the absence 
of a sulcus between it and the head. 

e. Place the palmar surface of one hand flat on the 

median section of the abdomen at the umbilicus, 

and press backward toward the spinal column. 

The child will be displaced to the side toward 

which its back lies and the liquor amnii to the 

other. Palpating with the other hand, the solid 

is readily distinguished from the fluid tumor. 

(Fig. 35.) 

Small parts are felt as nodules which glide freely about 

under the touch ; sometimes their outlines may be fully 

traced. Circular rubbing movements with the finger-tips 

help to identify them. The side on which they are felt is 

that opposite the foetal dorsum. In full anterior positions 

of the child's back the small parts may not be accessible 

to palpation. Small parts in the median section of the 

abdomen indicate a dorso-posterior position of the foetus. 

3. Examining the Lower Foetal Pole. — With both hands 



134 



ESSENTIALS OF OBSTETRICS. 



over the lower uterine segment just above Poupart's liga- 
ments, finger-tips toward the mother's feet, and palmar 



Fig. 36. 




Examining lower foetal pole. 



surfaces nearly facing each other, the lower foetal pole is 
caught between the hands. (Fig. 36.) In difficult cases 



PHYSIOLOGY OF LABOR. 



135 



the following manipulation helps to find the head : bring- 
ing the hands gradually nearer and nearer together, while 



Fig. 37. 




Grasping foetal head with hand over abdomen for locating cephalic prominence. 

placed as above described, move them as if to toss the 
head sharply from one hand to the other. 



136 



ESSENTIALS OF OBSTETRICS. 



The head feels hard and globular ; there is a lateral 
sulcus between it and the trunk ; in primiparse (not in 
multipara) it is in the pelvic excavation before labor. 

The breech alone is smaller, with all its component 
elements it is larger, than the head ; it lacks the hard and 
globular feel of the head, presents no sulcus, and it is 
never in the excavation before labor. If small parts can 

Fig. 38. 




Locating cephalic prominence by grasping the head with one hand over the 
abdomen. (Leopold and Saenger.) 

be felt just beyond either foetal pole that pole is almost 
surely the breech. 

The head in either iliac fossa indicates a cross-birth. 

After lightening the head may be found in the ex- 
cavation even in multiparas in one-third the cases, before 
labor. 

Cephalic Prominence. — When the head is in the brim 



PHYSIOLOGY OF LABOR. 



137 



the cephalic prominence is greater on the side of the sin- 
ciput. The location of the cephalic prominence aifords 
some aid in deciding whether the child's back lies to the 
right or the left. It is located by grasping the head with 
one hand held transversely across the suprapubic region 
(Figs. 37, 38), or by palpation with both hands (Fig. 39). 

Fig. 39. 




Locating cephalic prominence by palpation with both hands. (Leopold 
and Saenger.) 



The hand sinks more deeply in the excavation on the side 
opposite the prominence. 

4. Examining the Upper Foetal Pole. — With both hands 
over the upper uterine segment, finger-tips toward the 
mother's face (Fig. 40) and palmar surfaces nearly facing 
each other, the foetal poles are differentiated by the signs 
already given and by ballottement of the head. The 



138 



ESSENTIALS OF OBSTETRICS 



breech lacks the flexible attachment to the trunk which 
characterizes the head, and it has less mobility by reason of 
this and of its greater bulk when taken with all its com- 



Fig. 40. 




Examining upper fcetal pole. 



ponent parts. Ballottement of the head when in the lower 
uterine segment is possible only with excess of liquor 
amnii. 



PHYSIOLOGY OF LABOR. 



139 



5. Locating the Anterior Shoulder. — The hands are 
placed over the sides of the head and, with firm pressure, 

Fig. 41. 




Locating anterior shoulder. 



moved toward the breech ; the first obstacle they en- 
counter is the anterior shoulder. Usually it can be 
identified by its anatomical characters (Fig. 41). 



140 ESSENTIALS OF OBSTETRICS 

Location of the anterior shoulder within one or two 
inches of the median line indicates an anterior position of 
the child's back ; anterior shoulder several inches away 
from the median line indicates a posterior position of the 
back. 

6. Locating the Foetal Heart. — The place at which the 
foetal heart-tones are heard loudest is called the focus of 
auscultation. It is usually an area of about 7.5 cm., 3 
inches, in diameter. As a rule it lies nearly over the 
lower angle of the left scapula of the foetus, or at least 
the upper part of the foetal dorsum. Heart-sounds in 
the upper uterine segment indicate a breech, in the lower 
a cephalic presentation. The heart, however, is situated 
nearly midway between the ends of the foetal ellipse. In 
multiparas, therefore, in whom neither pole sinks into the 
lesser pelvis before labor begins, the location of the foetal 
heart-tones is of little value for the diagnosis of presenta- 
tion. 

Occasionally the focus of auscultation does not imme- 
diately overlie the heart. It may be found at some re- 
mote point owing to firmer contact of the foetus with the 
uterine wall at that point. 

The location of the foetal heart is especially useful in 
distinguishing between right and left and between an- 
terior and posterior positions of the child's back. Heart- 
tones to the left indicate a left, to the right a right, posi- 
tion ; heart-tones near the median line indicate an anterior, 
far from it a posterior position. 

External Pelvimetry. — Measurement of the external 
diameters requires the use of a suitable instrument. A 
good portable pelvimeter for external measurements is 
Schultze's or Collyer's. (Fig. 42.) 



PHYSIOLOGY OF LABOR. 141 

Marked asymmetry of the pelvis is sometimes apparent 
on external palpation. 

Interspinal and intercristal diameters both small indi- 
cates general pelvic contraction. Interspinal equal to or 
greater than the intercristal indicates antero-posterior flat- 
tening. For the external conjugate 7 inches maybe taken 




Collyer's pelvimeter. 



as the average lower limit in normal pelves. Yet vari- 
ations of J to 1 inch above or below this limit are ob- 
served. 

AYhen the external conjugate is below 6 J inches the pel- 
vis is surely contracted ; when above 8 inches the pelvis 
is almost surely ample ; within these limits, the question is 
in doubt, pending the internal examination. 



142 



ESSENTIALS OF OBSTETRICS. 



Method of Vaginal Examination and Internal 
Pelvimetry. 

The bladder and the rectum must be empty. Anti- 
septic precautions are to be observed as in examinations 
during labor. Measure the depth of the symphysis pubis, 
width of the subpubic angle, the bisischial, the sacro- 
pubic and the diagonal conjugate diameters, and note the 
size and shape of the sacrum. 

The transverse diameter at the outlet may be measured 
externally by taking the distance between the inner as- 
pects of the ischial tuberosities measured on a line drawn 

Fig. 43. 




Measuring the diagonal conjugate. 



through the anterior margin of the anus. It may be 
measured internally with the aid of a suitable instrument, 
or approximately by the hand. 



PHYSIOLOGY OF LABOR. 143 

The antero-posterior diameter at the inferior strait is ob- 
tained in a manner similar to that described below for the 
diagonal conjugate. It may more readily be measured 
externally with a pelvimeter. 

The diagonal conjugate is measured as follows : Passing 
the index and second finger into the vagina, the tip of the 
second is placed against the summit of the promontory, 
the radial edge of the hand resting against the subpubic 
ligament. The latter point of contact is marked with 
the index finger of the other hand. Withdrawing the 
hand the distance between the two points of contact is 
measured. This distance is the diagonal conjugate. 
(Fig. 43.) 

The true conjugate is found by deducting 1.3 to 2 cm., 
J to J inch, according to the depth and inclination of the 
symphysis pubis, from the diagonal — one-half inch when 
the symphysis measures less, three-fourths inch when the 
symphysis measures more, than 4.5 cm., If inch. 

The other diameters are estimated by palpating the walls 
of the cavity. 

General Preparations for Labor. 

Obstetric Armamentarium. — For general practice the 
obstetric bag should be equipped with obstetric forceps, a 
pelvimeter, a soft-rubber catheter, a hypodermic syringe, a 
fountain syringe, a uterine douche-tube of glass, needles, 
needle-forceps, aseptic sutures, hand brushes, a Sims' specu- 
lum, a sponge-holding forceps, a volsella, a curette and a 
yard of aseptic gauze. 

It should also contain four ounces of Squibb's chloro- 
form, an ounce of Squibb's ergot, a few drachms of 
chloral, morphine tablets, gr. J, fluid extract of veratrum 



144 ESSENTIALS OF OBSTETRICS. 

viride and antiseptic tablets of the biniodide or bichloride 
of mercury or either of the following powders : 

R. — Hydrargyri biniodidi, 

Potassii iodidi, aa, 5j- — M. 
Chart, no. viii. 
S. One to a quart of warm water, as an antiseptic solution. 

R . — Hydrargyri bichloridi, 

Acidi tartarici, aa 3j- — M. 
Chart, no. viii. 
S. One to a quart of warm water, as an antiseptic solution. 

The nurse should have ready a half dozen clean sheets, 
a dozen recently laundered towels, a dozen pieces of cheese- 
cloth, 45 cm., 18 inches, square, for wash-cloths ; two or 
three pieces of unbleached muslin for binders, a little over 
a meter long by 50 cm. wide, 1 J by J yard ; two surgically 
clean rubber sheets wide enough to reach across the bed 
(table oilcloth may serve when economy requires) ; scis- 
sors, two dozen shield-pins of medium size ; a bed-pan 
of earthenware or of agate ironware, two or three clean 
hand-basins of like material, a slop-jar, one or more new 
hand-brushes, plenty of hot and of cold water, a yard of 
strong linen bobbin, one-sixteenth of an inch in width, 
for tying the navel cord ; a woollen blanket to wrap the 
child in, an infant's bath-tub and a bath-thermometer, 
Castile soap, an ounce package of aseptic cotton for the 
navel dressing ; the child's clothing. 

Hand-brushes, scissors, cheese-cloths and the ligature for 
the funis should be wrapped in a towel and sterilized by 
steam or by boiling at the beginning of labor in a lj-per- 
cent. solution of sodium carbonate. They are kept en- 
veloped in the towel until wanted for use. Similar care 
should be taken with all other appliances that otherwise 



PHYSIOLOGY OF LABOR. 145 

might directly or indirectly be the source of infection to 
mother or child. 

The Lying-in Room. — The lying-in room should be a 
large, well- ventilated room, with sanitary plumbing, or 
none at all, preferably with a southern exposure. The 
room, the bedding and the clothing of the patient must be 
absolutely clean. 

Preparation of the Bed. Directions for the Nurse. — 
The mattress should be covered with a muslin sheet, and 
that with a rubber sheet large enough to reach across the 
bed. A clean muslin sheet is spread over the rubber and 
pinned fast to the mattress. Over that is spread a second 
rubber covered with a muslin sheet. Two or three fresh 
laundered sheets, twice folded, are placed in position to re- 
ceive and absorb the discharges. The rubber and the 
muslin sheets must be surgically clean. Table oilcloth 
may be substituted for rubber when economy requires. 

Labor Pad. — In place of the folded sheets an aseptic 
pad of cotton batting, cotton-waste, paper-wool or other 
absorbent material, covered with cheese-cloth, may be used 
to receive the discharges. It should be three feet square. 
A large Kelly rubber pad may be substituted for the ab- 
sorbent pad. 

Antisepsis. 

Antiseptic Agents. 

1. Dry heat at 284° F. — Exposure in an oven for half 
an hour may serve for utensils. 

2. Boiling for ten minutes, or steaming for half an hour. 
Boiling is best done in water to which 1J per cent, of 
sodium carbonate, c. p. (washing soda), has been added. 
The soda removes greasy matter and tends to prevent 

10 



aa gr. vijss. 



146 ESSENTIALS OF OBSTETRICS. 

metallic instruments from rusting, and boiling in the 
solution is a much more efficient germicide than boiling in 
plain water. 

3. Chemical Antiseptics. 

Mercuric iodide solution, 1 : 2000. 
R . — Hydrargyri biniodidi | 

Potassii iodidi j 

Aquae 1 ........ Oij. — M. 

Mercuric chloride (sublimate) solution, 1 : 20J0. 

R . — Hydrargyri bichloridi gr. vijss. 

Acidi tartarici gr. xl. 

Aqua? Oij. — M. 

Chlorinated soda solution, 1 : 10. 

R. — Liquor sodae chlorate gj. 

Aquae . . . . . . . . ^ix. — M. 

Creolin solution, 1 : 100. 2 

R . — Creolin 5iJ ss - 

Aquae Oij. — M. 



Carbolic solution, 1 :20.' 2 
R . — Acidi carbolici ) 

Glycerini j 

Aquae ........ Oij. — M. 



aa gjss. 



Peroxide of hydrogen in full strength, or diluted with 
one, two or four volumes of water, is a useful antiseptic. 
It has the advantage of being non-poisonous. 

Practical Bides for Antisepsis. 

Non-metallic utensils may be disinfected with any of the 
foregoing agents ; heat is the most efficient. 

Metallic instruments are best sterilized by boiling in the 
1 J-per-cent. soda solution. They may for convenience in 
handling first be wrapped in a towel. 

1 Best, boiled water. 2 Approximately. 



PHYSIOLOGY OF LABOR. 147 

Cloths, bed-linen, etc., are best sterilized by steaming. 
Flowing steam is most active. Dry heat does not pene- 
trate dressings well. 

When the chemical solutions are used exposure for at 
least a half hour is desirable. 

The obstetrician should wear a sterilized operating-gown 
to cover his clothing and prevent contact of his hands and 
arms therewith. 

Technique of Hand-cleaning. 

(a) Furbringer Method. 

1 . The nails are kept short and cleaned dry. 

2. The hands and forearms are scrubbed thoroughly 
with soap and hot water and a hand-brush for not less than 
live or ten minutes, giving special attention to the finger- 
tips and the free edges of the nails, using two or three 
changes of water and finishing in running water. 

3. The soap is thoroughly removed with sterilized 
water. 

4. The hands and forearms are held in the mercurial 
solution (1 : 2000) for five minutes. 

As an additional precaution the hands may be wet well 
with alcohol (80 per cent.) before immersion in the anti- 
septic solution. This helps to remove fatty matter and 
by dehydrating the skin makes the antiseptic sink more 
deeply. 

Hand-brushes should be steamed for ten minutes or 
boiled in the soda solution for the same length of time. 
(6) Permanganate Method. 

Steps 1, 2 and 3 as in (a). 

4. Immerse for two or three minutes in a warm satu- 
rated solution of permanganate of potassium in hot water. 



148 ESSENTIALS OF OBSTETRICS. 

5. Remove the permanganate stain by immersing in a 
warm saturated solution of oxalic acid made with steril- 
ized water. 

6. Rinse with sterilized water. 

7. Immerse for five minutes in a mercuric chloride 
solution, 1 : 500. 

With this method the hands may be rendered sterile to 
culture-tests. 

(c) Chlorinated Soda Method. 
Steps 1, 2 and 3 as in (a). 

Cover the skin with a paste made by wetting witfej 
boiled water a handful of fresh chlorinated lime. Rub 
the paste over the hands with a crystal of washing soda 
till it feels cold. Scrub well for five minutes with a 
sterilized brush. Rinse with sterilized water, then with 
alcohol, and finally with the water again. This, too, 
yields sterile results. 

(d) Boiled Gloves. 

Prepare the hands as in (a). 

Then put on thin rubber or lisle thread gloves which 
have been boiled for ten minutes. 

The gloves are especially useful when the hands are 
sore or have been recently exposed to virulent infection. 

After cleansing, to prevent reinfection of the hands, 
they must touch nothing that is not aseptic. They should 
be held for a moment in the mercurial solution before 
each internal examination. 

It should be remembered that the skin though super- 
ficially sterilized does not remain so for many minutes, 
since germs lodged in the sebaceous glands and hair fol- 
licles soon find their way to the surface. 

Lubricants. — As a lubricant for the hands, either a 



PHYSIOLOGY OF LABOR. 149 

1:500 solution of mercuric iodide in glycerin may be 
used, or they may be wet with the antiseptic solution. 
Keeping the hands smeared with the biniodized glycerin 
keeps the skin soft and maintains continuous disinfection. 
Glycerin recently sterilized by heating to 212° F. for ten 
minutes may be used instead of biniodized glycerin as a 
lubricant. 

The nurse should wear wash dresses recently laundered, 
and should prepare her hands, as the doctor does, before 
contact with the genitals of the obstetric patient. 

The patient, at the onset of labor, is given a bath and 
a change of clothing. Before the internal examination 
the nurse cleanses the external genitals, the thighs, and 
abdomen of the patient with soap and warm water for five 
minutes ; the soapy water is then removed and the parts 
gently scrubbed for five minutes with the antiseptic solu- 
tion. 

In case of yellowish, greenish or foetid discharges the 
vagina and cervical canal should be prepared in like man- 
ner, cleansing with soap and water, using gentle friction, 
and finally with an antiseptic douche continued for at 
least five minutes, with friction. The object is prophy- 
laxis, not alone against infection of maternal wounds but 
of the child as well, especially its eyes. 

The antiseptic may be the chlorinated soda or the creolin 
solution. Mercurial irrigation if used at all should be fol- 
lowed after five or ten minutes with a plain sterilized water 
douche to wash out the chemical as a precaution against 
mercurial intoxication. A more satisfactory disinfection 
is effected by douching twice daily for a week or two be- 
fore labor, when possible, with a mercurial solution or with 
a 2-per-cent. lactic-acid solution. 



150 ESSENTIALS OF OBSTETRICS. 

It is well for the nurse, after carefully cleansiug the ex- 
ternal genitals at the onset of labor, to apply a compress 
kept wet with Thiersch's solution, or a saturated boric-acid 
solution, to be worn during the first and the second stage. 

Examination of Patient During Labor. 

Scheme. 

1. Verbal. 

Precursory signs of labor : 

Lightening ; 

Frequency of urination and bowel movements. 
Signs of actual labor : 

Increased frequency of urination and defeca- 
tion ; 

Bloody discharge — the show ; 

Expulsion of mucous plug from the cervix; 

Rhythmic pains, first felt in the lumbo-sacral 
then in the lower abdominal regions. 

2. Abdominal. 

Pendulous abdomen ; 

Hydramnios ; 

Pathological growths ; 

One foetus or two ; 

Location of placenta ; 

Presentation, position and posture of the foetus ; 

Foetal heart-tones, rate, rhythm, force ; 

Bladder, empty or not; 

Hardness of the head ; 

Relative size of head and pelvis. 

3. Pelvic. 

Pudendum, rigidity, oedema, former injuries; 



PHYSIOLOGY OF LABOR. 151 

Vagina, mucosa healthy or not ; secretion nor- 
mal or not ; former injuries ; 

Rectum and bladder, full or empty ; 

Bony pelvis : diagonal conjugate and other di- 
ameters ; shape, inclination ; 

Cervix, how much dilated; dilatable; for- 
mer injuries; 

Bag of waters, size, shape, ruptured or not ; 

Presentation, position and posture of foetus ; 

Caput succedaneum, how large ; 

Stage of progress. 

In the internal examination vertex presentation is rec- 
ognized by the hard and globular character of the head, 
and by tracing the sutures and fontanelles ; the position 
is made out by locating the sagittal suture and finding 
which end is forward ; the posture by noting the relative 
descent of the fontanelles ; the stage of progress, in the 
first stage by the extent of cervical expansion, in the 
second by the situation of the leading pole, occiput, as 
relating to the landmarks of the birth-canal. 

Examine deliberately all accessible foetal parts with 
a firm touch. Examination is best begun during a pain 
and continued into the interval. The frequency and 
strength of the pains and the general condition of the 
patient, including her pulse and temperature, should be 
observed. 

The prognosis usually must be guarded ; it should be 
made as definite as the findings permit. All else being 
normal the duration of labor will depend on the strength 
and frequency of the uterine contractions and the ability of 
the patient to help them by voluntary effort. 



152 ESSENTIALS OF OBSTETRICS. 

Management of the Stage of Dilatation. 

Measures for the relief of severe pain are chloral, in closes 
of gr. xv in water, every fifteen minutes till three are given, 
opium, gr. j, or an equivalent dose of morphine or codeine. 
Yet opiates should seldom be given and only in the event 
of great pain and restlessness. 

Chloroform, by inhalation, is very rarely permissible in 
the latter part of the first stage. The use of chloroform 
at this time is almost certain to impair the efficiency of 
the pains. Once begun it cannot easily be discontinued 
till the expulsion of the child, and prolonged chloroform 
inhalation is a dangerous depressant. General anaes- 
thesia should be withheld, therefore, until absolutely 
required. 

Vaginal examinations should be as infrequent as is con- 
sistent with a proper knowledge of the case. If a careful 
ante-partum examination has been made a single internal 
examination will usually be sufficient for the first stage of 
labor. Nothing so surely protects the parturient against 
infection as the avoidance of all internal interference. It 
is frequently possible to conduct the labor to its termination 
with no vaginal examination at all. 

Special Directions. — Active measures for accelerating the 
first stage are permissible only when indicated by danger to 
mother or child. 

It is a general rule to remain with the patient, or at least, 
in the house, from the time the os externum has reached 
the size of a silver dollar. 

The patient must be advised not to keep the bed, not to 
bear down with the pains and to empty the bladder and 
the rectum frequently. The lower bowel should always 



PHYSIOLOGY OF LABOR. 153 

be cleared once or more at the onset of labor with an 
enema of warm water. Instructions should be given with 
reference to diet. 

The maternal and the foetal pulse-rate are to be noted 
from time to time. A foetal pulse below 110 or above 
160 to the minute should be regarded as a signal of dan- 
ger to the child. 

Management of the Stage of Expulsion. 

Taking the Bed. — The patient should take the bed when 
the second stage begins, sooner if the pains are severe or 
the membranes have ruptured. 

She should be dressed for the bed with her night cloth- 
ing turned up and pinned at the shoulders, and with a 
clean folded sheet fastened about the waist like a skirt. 
The sheet serves the purpose of protecting the patient's 
clothing and the upper part of the body from soiling with 
the genital discharges. These precautions simplify the 
duties of the nurse in cleansing the patient at the close of 
labor. 

Rupture of the Membranes. — The bag of membranes, if 
still unbroken, should be ruptured artificially when it 
reaches the pelvic floor. It may be torn with the finger- 
nail or punctured with a stout hairpin, previously flamed, 
or with a sharp-pointed scissors. The instrument is 
passed with its point resting on the finger as a guard and 
the bag punctured while tense, during a pain. 

Puller. — Unless the labor is over-rapid, the patient may 
be permitted, during the pains, to pull upon the sheet 
twisted into a rope and fastened at one end to the foot of 
the bed. The use of the puller increases the efficiency of 
the voluntary expulsive efforts. 



154 ESSENTIALS OF OBSTETRICS. 

Obstetric Position. — Generally the position may be left 
to the patient. For internal examinations the dorsal re- 
cumbent position is best. At the perineal stage the posi- 
tion most favorable from the standpoint of both the mech- 
anism and the management is the lateral. Occasional 
changes of posture relieve fatigue and promote the prog- 
ress of labor. 

Vaginal Examinations should be infrequent. It will 
seldom be necessary to examine internally oftener than 
once an hour at the most. A single examination at the 
beginning of the second stage usually is sufficient. This 
is generally desirable to make sure that the cord or a 
hand has not prolapsed and that no other irregularity is 
present. Once assured that all is normal, further inter- 
ference within the passages is not only unnecessary but 
is injurious. The progress of labor while the head is 
passing the brim may be observed by palpation over the 
lower abdomen. After the head has sunk well into the 
lesser pelvis the rate of descent may be watched by exam- 
ining through the pelvic floor, with the finger on the skin 
surface near the posterior vulvar commissure ; by deep 
pressure at this point the head can be felt before it rests 
on the floor. By these means internal manipulations may 
be reduced to a minimum, and sometimes they may be 
wholly omitted. 

Anaesthesia. — An anaesthetic, if properly administered, 
may be used with advantage in most labors during at 
least the latter part of the second stage. In obstetric 
anaesthesia the aim is to blunt the pain, not to abolish it. 
Here the anaesthetic is given for short periods and inter- 
mittently — with the pains only. At the moment of ex- 
pulsion it may usually be carried nearly or quite to the 



PHYSIOLOGY OF LABOR. 155 

Burgical degree. As a rule chloroform is preferred for 

Fig. 44. 




Giving chloroform with the towel inhaler and dropping-bottle. 

mere obstetric analgesia. Ether should be chosen when 
complete anaesthesia is required for obstetric operations. 



156 ESSENTIALS OF OBSTETRICS. 

Ether is equally applicable for partial anaesthesia in sim- 
ple labor and by some obstetricians is preferred, but it is 
not so pleasant. 

The excessive use of anaesthetics, especially chloroform, 
while it is very seldom the direct cause of death in labor, 
is not infrequently a contributing factor. 

It is generally a good rule to withhold anaesthetics as 
long as the pains are well borne without them. The pro- 
longed and too free use of chloroform during labor is 
capable of serious injury to the mother. It must not be 
forgotten that the strength of the uterine contractions is 
impaired by anaesthetics. 

Method. — Have the head low and the clothing loose, 
remove false teeth, examine the heart and protect the skin 
about the mouth and nose by smearing with vaselin or 
glycerin. A good inhaler is a towel spread over the head 
and lifted at its middle six or seven inches from the face. 
Ask the patient to breath rapidly when the pain begins. 
Drop on the towel opposite the mouth and nose one or 
two drops of chloroform at each breath. If ether is used, 
three or four drops at each respiration will be required. 
(Fig. 44.) 

Whatever effect is to be produced must be obtained be- 
fore the pain reaches its height. Normally at the acme 
of the uterine contraction the abdominal muscles are fixed 
and respiration is temporarily suspended. 

Regulation of the Expelling Forces. — If the pains are 
feeble they may be stimulated by simple means, such, for 
example, as postural measures. Summon the aid of the 
abdominal muscles. In over-rapid labor the pains may 
be moderated by the use of anaesthetics and by regulating 
the action of the voluntary muscles. Anaesthetics arrest 



PHYSIOLOGY OF LABOR. 157 

or retard expulsion according to the freedom of dosage. 
Unnecessary manipulation of the cervix must be avoided ; 
irritating the tissues lowers the resisting power and in- 
vites sepsis. 

Prevention of Pelvic-floor Lacerations. — The chief re- 
liance for preventing pelvic-floor injuries during the birth 
is a slow and gradual delivery of the head by its smallest 
diameters. Expulsion is to be retarded by anaesthesia and 
by the fingers held against the occiput. This permits the 
resisting structures to stretch. Not only the rate but the 
mechanism of expulsion must be regulated. Keeping the 
smallest circumference of the head in the grasp of the re- 
sisting girdle, press the head well up against the pubic 
arch as the forehead is about to escape. These measures 
reduce the strain on the soft parts. From the time the 
pelvic floor begins to bulge the birth of the head should 
rarely occupy less than a half hour. 

Shelling out the head between the pains, manipulations 
within the rectum and most similar measures that have 
been recommended for the prevention of so-called perineal 
ruptures, must be regarded as useless if not injurious. 
Supporting the pelvic floor by pressure with the hand is 
rational in so far as it crowds the head into the subpubic 
arch and thus relieves the tension of the facial structures 
of the floor. 

Episiotomy. — When much laceration is otherwise in- 
evitable incise the resisting ring at the introitus bilater- 
ally. Cut while the ring is tense during a pain. Pass a 
straight, narrow, blunt-pointed bistoury flatwise between 
the head and the cord-like girdle. Turn the cutting edge 
outward and cut horizontally, holding the knife parallel 
with the axis of the patient's body. The location of the 



158 



ESSENTIALS OF OBSTETRICS. 



cut should be one-third way from the median line pos- 
teriorly when the parts are fully stretched. The length 



Fig. 45. 




Author's method of regulating the birth of the fcetal head. 

of the incision should be about 1 inch, the depth \ inch. 
The incisions are sutured after labor. 






PHYSIOLOGY OF LABOR. 159 

Management of the Cord. — If coiled about the neck, 
slip the coils one by one over the head. Failing this, 
which is scarcely possible, cut the cord and deliver the 
trunk promptly. 

Delivery of the Trunk. — Hold the head well up toward 
the mother's abdomen and deliver the posterior shoulder 
by hooking a -finger in the axilla and lifting the shoulder 
over the posterior commissure. Disengage the posterior 
arm and then release the anterior shoulder. Extract the 
trunk slowly or leave its expulsion to nature. Powerful 
traction on the head should be avoided if possible, owing 
to the danger of inducing Duchenne's paralysis by stretch- 
ing the nerve-trunks of the brachial plexus. 

Ligation of the Cord. — As a rule, wait till notable pulsa- 
tion ceases or until the child cries lustily. By delaying 
the ligation of the cord for several minutes, till respira- 
tion is established, a gain of from one to three ounces of 
blood is effected, a matter of importance more especially in 
premature and in puny or anaemic children. This post- 
natal afflux of blood is probably brought about by the 
force of thoracic aspiration in the child. 

Tie the cord firmly with aseptic narrow linen bobbin 
2.5 cm., about one inch, from the umbilicus. A second 
ligation to control the placental end of the cord is re- 
quired in case of twins, since otherwise, if the placental 
circulations communicate the second child may be lost by 
hemorrhage ; in single births it is not necessary. Cut with 
surgically clean scissors 6 mm., about J inch, outside the 
ligature. Press the end of the stump with a sterile cheese- 
cloth to see if it bleeds ; if it does tie again. A thick cord 
should be pinched firmly before tying to press out the jelly 
of Wharton from the part to be ligated. 



160 



ESSENTIALS OF OBSTETRICS. 



Management of the Placental Stage. 
From the moment the head is born the hand should 
be held on the abdomen over the uterus till evacuation 
and retraction of the uterus are complete. Gentle fric- 
tion may be used if required to promote normal con- 
tractions. 




Impressing the placenta by the method of Creole. 



Delivery of the Placenta. Crede's Method. — When the 
placenta is not spontaneously expelled within thirty min- 
utes after the birth of the child the uterine contractions are 
to be reinforced by the method of Crede. At the acme of 
the pain ; not sooner, graspiug the fundus through the ab- 
dominal wall with the thumb in front and fingers behind, 



PHYSIOLOGY OF LABOR. 161 

compress the fundus firmly. (Fig. 46.) To the compres- 
sion should be added a moderate downward pressure in 
the uterine axis. To bring the uterine into line with the 
vaginal axis carry the fundus well back during the manipu- 
lation. Repeat the process with each pain till the placenta 
is expelled. The card should not be pulled upon to assist 
delivery till the placenta is in the vagina or in the lower 
uterine segment. 

If the first attempt fails ask the patient to strain for- 
cibly during the next manipulation. Almost invariably 
the placenta will be expelled promptly. 

Manual Extraction. — External measures failing after 
an hour, the placenta may be removed manually by seiz- 
ing its lower edge with the fingers passed through the 
cervix. 

Management of the Membranes. — On expulsion of the 
afterbirth pull very gently on the membranes till they are 
wholly detached. Should the uterus be contracted, wait 
till it relaxes lest a portion of the membranes still held in 
the grasp of the uterus be torn off and left behind. 

Examination of the Placenta and Membranes. — The pla- 
centa and the membranes should be inspected carefully to 
make sure no fragments have been left in the passages. 
The membranes are best examined by transmitted light to 
see that both amnion and chorion are complete. When 
viewed in this manner a single membrane is quite trans- 
lucent, both together somewhat opaque. Fragments of 
membrane wholly or partly in the vagina should be re- 
moved. When wholly in the uterus they are better left 
to be expelled with the lochial discharge. Manipulation 
within the passages, especially within the uterus, at the 
close of labor, exposes to infection. 
11 



162 ESSENTIALS OF OBSTETRICS. 

Laceration of the Passages. 

Cervical lacerations should be closed immediately by 
suture in case they give rise to troublesome hemorrhage. 
Otherwise immediate suture is generally inadvisable. 
Spontaneous union takes place, as a rule, in aseptic con- 
valescence. 

Method of Suture. — No anaesthetic is needed. The 
patient is placed in the dorsal recumbent or lithotomy posi- 
tion on the bed or a table. The cervix is drawn well down 
with a volsella. The traction usually controls the hem- 
orrhage for the time. The surfaces of the cervical wound 
are brought together and sutured with No. 2 plain or 
chromated catgut, the first stitch being passed above the 
angle of the tear. The sutures should be placed 2 cm., 
about J inch, apart. 

Lacerations of the Pelvic Floor. — The frequency of pel- 
vic-floor lacerations is in primiparse from 15 to 35 per 
cent., in multipara? about 10 per cent. 

Causes are : Narrow pubic arch ; a relatively small 
vulvo- vaginal orifice ; rigidity of the pelvic floor, ad- 
vanced age in primiparse — over thirty years; faulty 
mechanism ; too rapid delivery ; unskilled use of forceps. 

Character of the Injury. — Lacerations of the pelvic 
floor may be complete or incomplete. 

Incomplete lacerations may be external, internal or com- 
bined external and internal tears. 

In all except external lacerations the tear runs up into 
the vagina on one or both sides of the rectum, i. e., in one 
or both vaginal sulci. When the laceration is confined to 
one side it takes a nearly straight course, terminating below 
in the perineum and above in the vaginal sulcus. When 



PHYSIOLOGY OF LABOR. 163 

the injury extends into both vaginal sulci the tear presents 
l Y shape. 

Degrees of Laceration. — (1) External, not involving 
the muscles ; (2) to the sphincter ani ; (3) into the 
rectum. 

Treatment, (a) Time for Repair. — Lacerations at the 
vaginal orifice involving the muscular or the fascial struc- 
tures, should, as a rule, be sutured at the close of labor. 
Union, however, may be obtained by suturing at any 
time within a week or more if the wound is aseptic. Su- 
turing while waiting for the delivery of the placenta may 
save the necessity for renewed anaesthesia ; it is not ad- 
visable in extensive or complicated tears. 

(b) Suture Material. — For surface work silkworm-gut, 
for buried sutures No. 2 plain or chromated sterilized cat- 
gut is used. 

Catgut may be prepared by Fowler's method, boiling 
for an hour in absolute alcohol. Heating in cumol at a 
temperature just below 300° F. is the only method that 
ensures absolute sterilization. Sterile catgut put up in 
absolute alcohol in sealed glass tubes is secure against in- 
fection. Silkworm-gut is boiled in water or salt solution 
for ten minutes immediately before using. 

(c) Needle. — A slightly curved Hagedorn or other sur- 
gical needle, about two inches long, is suitable. Lange 
or Martin needles will be found satisfactory. Small and 
medium sizes are required. A common darning-needle 
will do in the absence of a better. It may be held in the 
fingers or in a needle-holder. 

(d) Ancesthesia is generally required. Chloroform is 
usually safe for the purpose if managed properly. Ether 
should be preferred. 



164 ESSENTIALS OF OBSTETRICS. 

Slight tears may sometimes be sutured with the aid of 
cocain anaesthesia. The cocain solution should be boiled 
immediately before using. It is most effective when in- 
jected at several points into the lips of the wound. Xot 
more than a grain can safely be used in this manner. 

(e) Operation. — The patient is placed in the lithotomy 
position with the hips at the edge of the bed or table. 
The knees may be held by assistants, or with a Kelly or 
Robb leg holder or with a Dickinson's sheet sling, as 
follows : Holding a sheet by diagonally opposite corners 
twist it loosely into a rope ; with the patient in the re- 
quired position pass the sheet sling under both knees, 
carry one end over one shoulder, across the back of the 
neck and over the other shoulder or under the arm to the 
front again ; pull taut and tie the ends together in front 
of the chest. 

Pack the vagina above the wound with sterilized strip 
gauze, to prevent the flow of blood over the field of opera- 
tion. Remember to remove the packing after placing 
the sutures. Press the wound surfaces with a sponge 
compress repeatedly till dry. Make out fully the charac- 
ter and extent of the injury. 

The aim should be to restore accurately the normal 
relations of the parts. Generally this may be promoted 
by catching the posterior vaginal wall with a volsella at 
what before rupture was the center of its lower end, 
and lifting this point nearly to the meatus urethra?, at the 
same time retracting the labia. The trough-shaped 
w T ound on one or both sides of the vagina will thus be 
plainly displayed. The vaginal wall is held in the position 
described till the sutures are laid. The plane of each 
suture should be nearly parallel with the skin surface of 



PHYSIOLOGY OF LABOR. 165 

the perineum, the deeper portion of the loop being nearest 
the skin. When the lacerations in the sulci are closed 
the remaining wound in the skin surface will be insignifi- 

Fig. 47. 




Tear running up one sulcus ; sutures in sulcus tied ; crown stitch in place. 

cant. It may be brought together with a single crown 
(Fig. 47) or with two or three interrupted sutures. 

The stitches in the sulci should be placed at intervals of 
J inch, beginning at the upper or vaginal angle of the 
wound. Enter the needle close to the edge of the wound, 
give it a fairly deep lateral sweep through one lip, emerg- 
ing just short of the bottom of the wound, and pass it in 
reverse direction through the other lip. Care will be 
needed to avoid passing the needle into the rectum. The 
loop after the suture is tied should be nearly circular. 



166 



ESSENTIALS OF OBSTETRICS. 



As the sutures are laid the opposite ends of each are 
knotted together or held with catch-forceps till they are 
ready to tie. When the sutures are placed they are tied 
tightly enough barely to coapt, not to constrict, the 
wound surfaces, first removing the gauze packing and 
clearing the wound of blood clots. If silkworm-gut is 
used the ends are left long to facilitate removal. (Figs. 
48, 49, 50, 51.) 





Tear running up both sulci ; sutures laid iu both. 



One sulcus closed. 



Lacerations entering the rectum may be sutured on 
three sides — the rectal, the vaginal and the periueal or 
skin side (Fig. 52), or the rectal suture may be omitted 
and the rectal mucous membrane be closed with buried 
catgut. (These are not shown in the figures.) 

When the external sphincter is completely severed one 
or both muscle ends may be retracted within the tissues or 
may stand out plainly projecting above the wound surface. 
Draw out the ends if necessary with a tenaculum ; pass two 



PHYSIOLOGY OF LABOR 



167 



or three No. 1 plain catgut sutures through each end, 
carry them across and pass them through the opposite end. 

The internal sphincter should be closed with a figure of 
eight suture passed close to the rectal mucous membrane 
and parallel with it. 

To relieve the buried sphincter sutures of too great 
strain they should be reinforced with one or two silkworm- 
gut sutures as follows : Enter the needle from the skin sur- 





* 



Both sulci closed ; crown stitch in place. 



All sutures tied. 



face one-fourth inch from the edge of the tear, carry it up 
directly through the external sphincter and beyond through 
the lip of the wound close to the rectal wall and parallel 
with it, pass it across above the angle of the tear just short 
of the mucous membrane of the rectum and carry it down 
symmetrically through the opposite lip. (Figs. 51, 52.) 
A second silkworm-gut suture is passed in similar man- 
ner in a plane a little more remote from the rectal wall. 



168 



ESSENTIALS OF OBSTETRICS. 



The remainder of the wound is then closed as in in- 
complete lacerations. 

Anterior or lateral tears of the vagina or of the vulvo- 
vaginal orifice should be sutured. 



Fig. 52. 




Tear entering rectum ; sutures laid in three series, one rectal, one vaginal and one 
from the skin surface. 



Old lacerations sustained in a previous labor, and 
which have not been repaired, may sometimes be repaired 
with advantage at this time. The method does not differ 
from that usually employed in the secondary operation. 



PHYSIOLOGY OF LABOR. 169 

After-care. — It is unnecessary to bind the knees together. 

The catheter is usually required for a time after suture 
of the pelvic floor. It should be omitted if possible. 
Care must be used to prevent the urine from trickling 
into the vagina or over the wound surfaces. 

The bowels are opened on the second day and once 
daily thereafter. The nonabsorbable sutures are removed 
on the eighth or ninth day. 

Care of the Patient at the Close of Labor. 

Retraction of the Uterus. — For at least a half hour af- 
ter delivery of the placenta the uterus must be watched, 
holding the hand over it upon the abdomen. Gentle fric- 
tion is used if necessary to promote contraction. One or 
two doses of the fluid extract of ergot of a half drachm 
each are generally required, especially when chloroform 
has been given. Ergot is useful as a prophylactic, not 
only against postpartum hemorrhage, but against puer- 
peral infection, since it tends to prevent the formation 
and retention of blood-clots in the uterus. Moreover, by 
limiting the blood-supply it promotes involution. It may 
be administered by the mouth or subcutaneously. 

Cleansing. — The nurse bathes the external genitals and 
soiled parts of the patient's body with sterilized water or 
with a weak antiseptic solution, and changes her linen 
and bed-linen if soiled. Fresh boiled cheese-cloths, not 
sea-sponges, are to be used for bathing. Sea-sponges are 
difficult to clean. 

Vulvar Dressing. — The external genitals are covered 
after cleansing with a dressing, the lochial guard. A 
folded napkin is commonly used. It should be sterilized 
by steaming or boiling and dried before using. 



170 ESSENTIALS OF OBSTETRICS. 

Instead of the napkin a special dressing may be made 
of absorbent cotton, cotton batting, cotton-waste or other 
absorbent material loosely packed in a cheese-cloth en- 
velope. It should be ten inches long, four inches wide 
and two inches thick. A tail-piece about ten inches long 
at each end of the pad serves for pinning to the abdom- 
inal binder. The pads are burned after using. 

Draw-Sheet. — This is a clean sheet folded to four 
thicknesses. It is placed under the patient's hips to pro- 
tect the bed, and changed as often as soiled. 

The Abdominal Binder is best made of a straight piece of 
unbleached muslin, a yard and a quarter long and half a 
yard wide. When applied it should reach just below the 
trochanters ; it ought to be moderately tight for the first 
twelve hours, subsequently looser. 

The binder is not indispensable, but the support it gives 
is usually grateful to the lying-in woman during at least 
the first few hours or days after labor. 

The Condition of the Mother, especially the pulse and 
the temperature, the amount of lochial flow and the firm- 
ness of the uterus, should be noted before leaving. 

Instructions to the Nurse. — The nurse should receive 
directions with reference to the care of the patient and 
particularly in the matter of sleep, diet, evacuations of 
the bladder, nursing the child and watching the amount 
of bloody flow. A drachm of the fluid extract of ergot 
may be left with the nurse to be given in the event of 
hemorrhage, a grain or two of opium, or its equivalent, 
for use if required for severe after-pains, and a suitable 
antiseptic to be used in cleansing the genitals. All needed 
instructions should be given with reference to the care of 
the child. Within the first hour or two after birth the 
navel should be reexamined for possible bleeding. 



CHAPTER IV. 
PHYSIOLOGY OF THE PUERPERAL STATE. 

COURSE AND PHENOMENA. 

Post-partum Chill. — Frequently a chill follows the birth 
of the child. It is due probably to the lessened heat- 
production incident to the abrupt cessation of the mus- 
cular efforts of labor and has no pathological significance. 

The Pulse-rate. — The pulse-rate as a rule falls shortly 
after labor below the usual standard. For a period of a 
week or more it may remain below 60, in exceptional in- 
stances as low as 40, to the minute. 

Temperature. — The maximum physiological tempera- 
ture for the first four or five days of the puerperium is 
99 J°, thereafter 99° F. A rise of one or two degrees 
above these limits though common is not to be regarded 
as strictly physiological. 

Urination. — Owing to lowered intra-abdominal pres- 
sure, to urethral spasm, to the bruised, swollen and sensi- 
tive condition of the structures about the urethra and to 
other causes, the patient is liable to retention of urine in 
the first few days following labor. The secretion is 
greatly increased after child-birth and over-distention of 
the bladder not infrequently results. 

Peptonuria. — Peptonuria is normal in the puerperal 
state, peptone being a product of uterine involution. 

Bowel Movements. — Sluggish action of the bowels is 
the rule. 



172 ESSENTIALS OF OBSTETRICS. 

Condition of the Uterus. — The upper segment is 
thick and moderately firm. The lower segment remains 
thin and relaxed for about twelve hours after child birth. 
Subsequently it gradually regains its shape and firmness. 

The lymph-spaces or blood channels are greatly en- 
larged, a condition favorable to resorptive activity and 
which constitutes one of the elements of septic danger in 
the lying-in period. 

The Cavity. — The deeper layer of the decidua remains 
to be shed piecemeal during the lochia! flow. Shreds of the 
outer superficial layer, too, are retained to be loosened and 
discharged with the lochia. The placental site is slightly 
elevated above the general surface and is studded with 
small blood-clots lodged in the mouths of the vessels. 
The cavity at first contains blood and blood-clots and 
later its walls are smeared with a muco-sanguinolent 
fluid. 

Involution. — Involution is the process by which the 
hyper trophied structures of the uterus and other genital 
organs are restored to the non-gravid condition normal to 
the parous woman. It is essentially a process of fatty 
degeneration resulting from the lessened blood-supply. 
The endometrium is wholly renewed. 

Uterus. — The uterus at the close of labor measures, 
externally, 10 to 12.5 cm. in width by 18 to 20 cm. in 
length, 4 or 5 by 7 or 8 inches ; the thickness of its 
walls is 2.5 to 3.7 cm., 1 to 1 J inch ; the depth of the 
cavity is 

At the close of labor, about . . 15.0 cm., 6 inches. 

" tenth day .... 10.7 " 4£ " 

" second week . . . . 9.7 " 3-g- " 

" third week .... 8.8 " 3J " 

" fourth week . - . . . 8.0 " 3| " 



PHYSIOLOGY OF THE PUERPERAL STATE. 173 

After involution is complete the thickness, the width 
and the length of the uterus are approximately 1, 2 and 
3 inches respectively. 

It will be seen that in the parous woman the organ is 
somewhat larger than in the virgin state. 

The situation of the fundus at the close of labor is nearly 
midway between the umbilicus and the pubic bones ; a few 
hours later it is just above the umbilicus and usually the 
uterus is dextroverted ; by the tenth day, if involution has 
gone on normally, it is at the level of the brim. The 
height of the fundus, however, varies with the fulness of 
the bladder and the rectum. 

The weight of the uterus at the termination of labor is 
about thirty-five ounces, at the end of the first week it is 
sixteen ; at the end of the second week, twelve ; and at 
the end of the third week, eight ounces. After involu- 
tion is complete it weighs ten to thirteen drachms — one 
and a half ounce nearly. 

The duration of uterine involution is usually six weeks, 
but it frequently reaches eight or even ten weeks. 

Involution of the uterus is slower in non-nursing 
women, after twin births, premature labor, much hemor- 
rhage, retention of secundines, and is partially arrested in 
endometritis and by getting up too soon. It may be re- 
tarded by violent emotional disturbance. 

The Cervix. — The cervix is soft and shapeless, having 
an almost gelatinous consistence at the close of labor. 
Within twelve hours it begins to be gradually re-formed. 

The os internum is large enough to admit two fingers 
at the end of twenty-four hours. The os externum will 
admit one finger after seven to fourteen days. Involution 
goes on proportionately to that of the body of the uterus. 



174 ESSENTIALS OF OBSTETRICS. 

The lower border is permanently notched to a greater or 
less extent in parous women. 

The Vagina. — The hypertrophied vaginal walls are 
much relaxed after labor. Their involution progresses 
with that of the uterus ; the vagina is not wholly restored 
to the nulliparous condition, however. 

Other Pelvic Structures. — The ovaries and tubes, the 
muscular structure of the pelvic floor, of the abdominal 
walls and all other structures which have undergone 
hypertrophy during pregnancy participate in the retro- 
grade process and are partially or wholly restored to their 
ante-partum state. 

After-pains. — Periodical uterine contractions continue 
for a few hours or days post-partum ; usually they are 
more or less painful in multiparas owing to the greater re- 
laxation of the uterus in women who have borne children 
and the consequent liability to retention of blood-clots at 
the close of labor. Generally they are not so in primi- 
parse. They accomplish and maintain the retraction of 
the uterus and are, therefore, conservative when not too 
severe. Normally they cease altogether by the third or 
fourth day. After-pains are likely to be intensified while 
the child is nursing. 

The Lochia. — The lochia are the genital discharges which 
follow labor. They are more or less bloody for four or 
five days, lochia rubra and they contain shreds of decidua 
and of placental tissue ; then they become sero-sanguino- 
lent, lochia serosa, for two or three days ; finally they are 
of a creamy appearance, lochia alba, and contain fat- 
granules, epithelial cells, leucocytes and cholesterin. For 
a week or more after labor their reaction is alkaline, then 
neutral or acid. The total amount is about three and a 



PHYSIOLOGY OF THE PUERPERAL STATE. 175 

quarter pounds, The duration of the discharge is in nor- 
mal cases from two to four weeks. 

MANAGEMENT OF THE PUERPERAL STATE. 

Post-partum Visits. — As a rule the patient should be 
seen within twelve hours after labor, except when a com- 
petent graduate nurse is in charge, and once or twice 
daily for the first three days ; once daily thereafter until 
the seventh is the rule in normal cases. Occasional visits 
should be made during the remainder of the post-partum 
month. 

The First Visit. — A systematic examination should be 
made at this and each succeeding visit. The general con- 
dition of the mother, the pulse and the temperature should 
be noted. Learn the amount and character of the lochia. 
The binder should be loosened and the uterus examined 
by the abdomen for size, firmness, tenderness. Observe 
in the abdominal examinations whether the bladder is 
over-filled. Learn if it has been evacuated and the quan- 
tity of urine voided. Inquire if the patient has had suf- 
ficient sleep and proper diet. The child should be looked 
after. Ascertain whether it has passed urine and me- 
conium as evidence that the passages are pervious ; if 
there has been any discharge from the eyes or bleeding 
from the navel, and what the temperature is per rectum. 

Subsequent Visits. — Especially to be observed at the 
daily visits are the pulse, the temperature, the condition 
of the breasts, nipples, bladder, the amount and character 
of the lochia, the involution of the uterus and the general 
condition of the mother. The pelvic contents should be 
examined by the bimanual method once or more during 
the third or fourth week. Observe whether the introitus 



176 ESSENTIALS OF OBSTETRICS. 

vaginae is normally closed, the vagina intact, the broad 
ligaments free from exudates or adhesions, whether the 
cervix is lacerated or gaping, and note the size, shape, 
position, density and mobility of the uterus. 

Too long continuance of the lochia is usually associated 
with some degree of sepsis in the uterine cavity. Per- 
sistence of the bloody flow in the third week, especially 
if accompanied with sacral pain, should excite suspicion 
of retrodisplacement of the uterus. 

The case should not be dismissed wholly until involu- 
tion is complete and the pelvic organs are entirely re- 
stored to the normal non-gravid state. 

The condition of the child should be noted at each visit. 

Evacuations of the Bladder. — Owing to the danger of 
overdistention the bladder should be emptied within six 
hours after labor and once in six or eight hours subse- 
quently. 

Retention of Urine. — Inability to void the urine may 
sometimes be relieved by hot fomentations over the meatus 
urethra?, a rectal injection of warm water, suprapubic 
pressure and if need be a sitting or half-sitting posture 
during attempts at urination. After the first six or eight 
hours it is generally better to allow the patient to get out 
of bed to use a commode than to pass the catheter. 
When the labor has been unusually severe or the pelvic 
floor has been badly torn and been sutured the patient 
must constantly keep the recumbent posture for at least 
several days. 

Bowel Movements. — The bowels are to be opened on 
the second or third day and once daily thereafter. For 
this purpose a simple laxative, an enema of warm water, 
Oj, or of a saturated solution of Epsom salt, oj-ij, or a 



PHYSIOLOGY OF THE PUERPERAL STATE. 177 

rectal injection of undiluted glycerin may be given. For 
internal use citrate of magnesium, the compound rhubarb 
pill, fluid extract of cascara or a cascara tablet is suitable. 
In case of hemorrhoids a quarter grain of the aqueous 
extract of aloes is recommended. 

After-pains. — After-pains, if severe enough to prevent 
sleep, may be relieved by one or two doses of opium, gr. 
J-j, by phenacetin, gr. v, by chloral hydrate, gr. xx, or 
by inhalation of 5 or 6 minims of nitrite of amyl. The 
use of opium, however, should be avoided if possible. 

Restorative Measures. — Restorative measures are rest 
and sleep, as generous a diet as the patient can digest, 
tonics (iron, quinine and strychnine) and sometimes stim- 
ulants. Sleep is especially important. 

Antisepsis. — Strict cleanliness of the patient's person, 
linen and bed-linen is imperative. 

The nurse should change the vulvar dressing every 
three to six hours during the first three days, and there- 
after often enough to prevent the least putrefactive odor. 
The external genitals, their immediate surroundings and 
other parts of the body which may be soiled by the dis- 
charges, should be cleansed carefully with an antiseptic 
solution at each change of the dressing. Vaginal or 
uterine douches are to be used only in the presence of 
sepsis or of fetor not controlled by rigid external cleanli- 
ness. 

The nurse should be scrupulously clean. She should 
wear wash dresses, frequently changed, and be as careful 
in the observance of a strict asepsis as the doctor is re- 
quired to be. 

Diet. — Usually the diet must be restricted to liquid or 
light solid food for the first day, often for a longer period 
12 



178 ESSENTIALS OF OBSTETRICS. 

if the patient is much exhausted or has taken an anaes- 
thetic. Milk, gruels, beef essence, animal broths, soft- 
cooked eggs, oysters, boiled custard, oatmeal mush or 
wheaten grits well cooked, dry toast and weak tea or 
cocoa are suitable. After the first two or three days, in 
the absence of exhaustion, fever, indigestion or loss of ap- 
petite, a moderately full diet generally may be permitted. 
Convalescence goes on more rapidly under proper feeding. 
Either excess or too great a restriction in the matter of 
diet must be avoided. Pains must be taken to adapt 
both the quality and the quantity of food to the needs of 
the individual patient. 

Tardy Involution of the Uterus. — Useful measures 
for promoting involution are the following : Gentle fric- 
tion applied for ten minutes, twice daily, with the hand 
on the abdomen ; the abdominal wall is moved in a circu- 
lar direction over the uterus ; galvanism may be used, 
ten to twenty milliamperes, one electrode over upper part of 
the sacrum, one upon the abdomen over the uterus, sitting 
ten minutes twice daily ; faradism applied in a like manner, 
is still more effective. Extract of ergot, gr. j, t. i. d., is 
useful. A hot vaginal douche, two or three gallons, tem- 
perature 120° F., once or twice daily, yields good results. 
Curetting is indicated in case of hypertrophied decidua. 

Active interference is not called for in slight departures 
from the normal rate of involution. Here all that is 
needed is a little longer period of rest than is the rule in 
strictly normal conditions. 

Use of the Catheter. — Catarrh of the vesical neck fre- 
quently results from infection carried on the catheter. 
Catheterism, therefore, should be withheld if possible, and 
when required should conform to the following rules : 



PHYSIOLOGY OF THE PUERPERAL STATE. 179 

The instrument, if to be used by the nurse, should be 
a soft -rubber catheter. The catheter is boiled for ten 
minutes immediately before using, and after sterilizing 
must be handled only with surgically clean hands. 

The patient lies on the back with the knees drawn 
apart. She or an assistant retracts the labia to fully ex- 
pose the meatus urethra? and holds them apart until the 
catheter is passed. 

The meatus and its surroundings are carefully cleansed 
and disinfected. 

The catheter, lubricated with sterilized vaselin, is 
passed 4 cm., about 1 J inch, or until the urine begins to 
flow. 

The urine is collected in a cup or small bowl. The 
evacuation of the bladder is repeated every eight hours. 
Care should be taken to prevent the entrance of urine 
into the vagina and its contact with genital wounds. 
The instrument is cleansed carefully after using. 

Washing out the bladder with a few ounces of sterile 
saturated boric acid solution after catheterizing is useful 
as a prophylactic against cystitis. 

Regulation of the Lying-in Period. 

First Week. — The patient keeps the bed. As a rule, 
after the first few hours she may assume a half-sitting 
position, if necessary, for evacuation of the bladder or 
bowels. 

Second Week. — She maintains a recumbent posture on 
the bed or lounge ; may sit up in bed during meals and for 
urination and for bowels movements. 

Third Week. — She sits up in a chair all or part of the 
day. 



180 ESSENTIALS OF OBSTETRICS. 

Fourth Week. — The patient has the liberty of the room ; 
at the end of the month, if all goes well, she can leave 
the room. 

The duration of the lying-in, however, must obviously 
vary according to the rate of uterine involution and the 
general progress of convalescence. 

LACTATION AND NURSING. 

Colostrum is the thin, slightly viscid, yellow liquid fur- 
nished by the mammary glands of the puerpera before the 
true milk secretion begins. It contains epithelial cells, 
fat-globules and certain bodies called colostrum corpuscles, 
and is rich in proteids and saline matter. To the latter 
are ascribed by some authorities its moderate laxative 
properties. Normally no colostrum corpuscles should be 
found in the milk after about the tenth day. 

The true milk secretion is usually established by the 
third day in primiparse, the second in multipara. 

Signs of deficient lactation are : Mother's breasts per- 
sistently flabby, child not satisfied and showing signs of 
inanition. The milk may be at fault in quality or in 
quantity. Clinically the best evidence of the amount 
and character of the milk secretion is to be had by not- 
ing whether the infant gains normally in weight. The 
average gain is five or six ounces per week for the first 
five months, and a pound monthly for the remainder of 
the first year. The child's weight should be taken 
weekly. 

The secretion is at fault in quantity, quality, or both, 
in from 10 to 20 per cent, of mothers. 

Measures for Increasing the Secretion. — Generous 
diet, milk, tonics, especially strychnine, and attention to 



PHYSIOLOGY OF THE PUERPERAL STATE. 181 

hygiene are the best galactagogues. Milk may be taken as 
a part of each meal, not as an addition to the usual feed- 
ing. Used in this manner it is generally well borne. 
Faradism applied directly through the breasts, once or 
twice daily, positive pole on nipple, may help. Somatose 
3 or 4 teaspoonfuls daily in cocoa or in milk has some 
value. Beans, lentils, parsnips and most foods contain- 
ing phosphorus, increase the quantity of milk. Thy- 
roid extract, gr. j, three or four times daily, improves the 
quantity and quality of the secretion ; massage of the 
breasts and especially of the abdomen from below upward 
with a view to increasing the blood supply to the breast 
helps. Malt liquors are not to be recommended as galac- 
tagogues. Coffee diminishes the secretion of milk. 

Care of the Breasts and Nipples. — The nurse should 
cleanse the nipples after each nursing with a bland anti- 
septic solution, such as a saturated aqueous solution of 
boric acid to which one-eighth part of glycerin has been 
added. It is well to cleanse the child's mouth in like 
manner before nursing. The nurse should be warned of 
the risk of carrying infection to the nipples or to the 
child when her hands are frequently soiled with lochia. 
Excessive nursing must not be permitted. The nipple is 
injured by long-continued maceration. 

Gentle massage of the breasts may be useful in simple 
milk engorgement ; it should be prohibited in inflamma- 
tion. 

Painful distention of the breasts may be relieved by 
saline cathartics and partial abstention from liquids, and 
by the use of the compression binder firmly applied. 

Contra-indications to Suckling the Infant. — Among 
the conditions which should prohibit nursing are recent 



182 ESSENTIALS OF OBSTETRICS. 

syphilis if the child is not infected, tuberculosis, marked 
anaemia, epilepsy, poor quality or very deficient quantity 
of milk, pregnancy. 

THE CHILD. 

Condition at Birth. 

Weight. — The weight of the newborn infant is from 
3175 to 3288 grammes, 7 to 1\ pounds, males weighing 
more than females by about a quarter of a pound, and 
first less than subsequent births. 

A loss of weight takes place during the first three 
days, amounting to six or eight ounces. Normally the 
child regains its initial weight by the end of the first 
week or ten days. The birth-weight is doubled at five 
months and trebled at fifteen. 

Measurements. — See page 92. 

Temperature. — The temperature ranges from 98.6° 
to 99° F., but is easily influenced by slight causes. Con- 
siderable elevation of temperature is frequently observed 
in innutrition of newborn infants. 

Circulation. — The pulse-rate ranges from 120 to 140 
per minute. The ductus arteriosus, the ductus venosus 
and the umbilical vein are obliterated in a week or ten 
days. The foramen ovale generally closes within the 
same period ; sometimes the upper part remains perma- 
nently open. The umbilical arteries are obliterated in 
their upper portions within five days, the lower parts re- 
maining open to form the superior vesical arteries. 

Respiration. — The respiratory tract is devoid of air 
till the first respiratory effort, and the lungs are therefore 
collapsed. The air-tract may contain blood and vaginal 
mucus drawn into it by premature efforts at respiration. 



PHYSIOLOGY OF THE PUERPERAL STATE. 183 

The first respiratory movement is due in part to air-hunger 
from arrest of the maternal supply of oxygen, and in 
part to reflex contraction of respiratory muscles excited 
by contact of air with the moist surface of the skin. The 
average rate of respiration in the newborn infant is 45 
per minute. 

Skin. — The skin of the child's back and of the flexor 
surfaces of the limbs is more or less thickly covered with 
a cheesy coating, the vernix caseosa, which consists of 
fatty matter, epidermal scales and sebaceous material. 
The epidermis is partly exfoliated in the first two or 
three days, leaving the skin red and irritable. 

Bowels. — The contents of the intestines, meconium, 
consist of intestinal secretions and bile, together with 
lanugo and epidermal scales derived from swallowed 
liquor amnii. The meconium is passed off and the stools 
become feculent within the first three or four days. 

Genito- urinary Organs. — The bladder usually con- 
tains urine at birth. The specific gravity of the urine is 
1005 to 1010. Albumin and sometimes sugar are pres- 
ent. Uric acid deposits simulating blood stains are often 
observed on the napkin. 

In boys both testicles have descended into the scrotum. 
The preputial orifice is usually too small to permit easy 
retraction of the foreskin. The prepuce is normally 
adherent to the glans in the newborn ; sometimes it re- 
quires to be stripped back by freeing the adhesions 
when the latter are abnormally firm and give rise to irri- 
tation. 

Nervous System. — The nervous system is much more 
irritable and the nerve-centers more unstable than in later 
life. 



184 ESSENTIALS OF OBSTETRICS. 

Special Senses. — The sensibility of the skin is feeble 
at birth, but it is fully established within the first day or 
two. The taste is sensitive to strong impressions. 

The newborn infant is deaf at birth, since the meatus is 
closed and the middle ear devoid of air. Loud sounds are 
audible within a few hours. The retina is sensitive to light. 

Secretions. — The lachrymal and the sweat glands are 
not, as a rule, developed in the first few months. Little 
saliva is secreted. The amylolytic function is feeble dur- 
ing the first few months. 

Caput Succedaneum. — The caput succedaneum usu- 
ally subsides within twenty-four hours, and the distortion 
of the head from moulding disappears in the course of two 
or three weeks. 

Management of the Newborn Child. 

Respiration. — To inflate the lungs, provoke deep inspi- 
rations by blowing upon the face, by dashing a few drops 
of cold water upon the face and chest, or by gentle flagel- 
lation. Suspending the child by the feet promotes drain- 
age from the respiratory tract and at the same time the 
flow of blood to the brain. 

Asphyxia Neonatorum. — Asphyxia in the newborn 
infant is generally the result of injuries sustained during 
birth. Compression of the cord, premature separation of 
the placenta, pressure upon the foetal head in prolonged 
and difficult labors and especially in forceps operations, 
are among the most common causes. The prognosis 
varies with the degree of asphyxia. It is generally good 
in the cyanotic and grave in the pallid stage. 

Treatment. Preparatory Measures. — Clear the mu- 
cus from the throat with the finger wrapped with a wet 



PHYSIOLOGY OF THE PUERPERAL STATE. 185 

soft linen, or, better, by aspiration with a soft-rubber 
catheter. In marked venous congestion one or two 
drachms of blood may be allowed to flow from the cord. 
If the child is pale and collapsed a rectal injection of 
water, at a temperature of 105° to 108° F., should be 
given. Suspension by the feet is useful. The normal 
temperature is best maintained by keeping the child's 
trunk and lower extremities for the larger part of the 
time immersed in water at 98J° F. 

Direct Insufflation. — The child is laid upon its back ; the 
head is partially extended by placing a fold of blanket 
under its neck ; the face is cleansed and covered with a 
clean towel. To prevent inflation of the stomach the hand 
is held firmly on the epigastrium. AYith the mouth 
against the towel directly over the child's mouth the 
operator expands its lungs by breathing gently into them. 
This is repeated sixteen to twenty times per minute as 
long as the heart beats. 

Schultzes Method. — Suspend the child by the shoulders, 
face from the operator, holding a thumb in front and two 
fingers over the posterior aspect of each shoulder with an 
index finger caught in each axilla — inspiration. The pres- 
sure of the thumbs should be relaxed to assist inspiration. 

Invert the position by swinging the trunk and lower 
limbs upward and toward the operator's face, flexing the 
body in the lumbar region — expiration. 

In feeble infants this method must be used with great 
caution, if at all, owing to the shock involved. This and 
direct insufflation are the most effectual methods for the 
resuscitation of stillborn infants. 

Sylvester's Method. — Place the child in a supine position, 
with the head well extended by a fold of blanket under 



186 ESSENTIALS OF OBSTETRICS. 

its neck. For inspiration draw the arms well above the 
head. For expiration place them by the sides and gently 
compress the thorax. 

Byrd's Method. — The child is held supine upon the 
hands of the operator at right angles to the forearms. 
For inspiration the radial borders of the hands are low- 
ered ; for expiration they are raised. 

Faradism. — A weak faradic current may be employed 
when the respiratory movements are persistently feeble ; 
one pole is applied to the nuchal region and the other 
over the epigastrium. 

Laborde's Method. — Gentle intermittent traction on the 
tongue. 

Incubation. — An infant prematurely born will gener- 
ally require to be kept in an incubator for as many weeks as 
it is premature. It should be removed from it only for feed- 
ing or bathing. The temperature in the incubator should 
at first be about 90 °, and gradually be lowered to that of 
the room during the few weeks preceding the final removal 
of the child. A thermometer is kept in the compartment 
with the child. Ample ventilation must, of course, be 
provided. 

Rectal Injection. — It is well to order a rectal injection 
of a tablespoonful of warm water to be given soon after 
birth as a means of detecting at once possible occlusion of 
the rectum — atresia ani. 

Bathing. — The face is bathed on birth of the head and 
the eyes are cleansed and carefully dried as a prophylactic 
against ophthalmia. The instillation of a drop of Crede's 
solution (nitrate of silver, gr. x ad Sj), or of a protargol 
gr. xl ad 5j, is the rule in hospitals and may be practiced 
in private cases. It should not be omitted in family 



PHYSIOLOGY OF THE PUERPERAL STATE. 187 

practice when there is reason to suspect that the secretions 
of the birth canal are infectious. 

Protargol is much less irritating than the nitrate of 
silver and is equally effective. 

A few drops of lemon juice may be substituted for silver 
salts (Pinard). 

The body is smeared with sweet oil or vaselin to facili- 
tate the subsequent removal of the vernix caseosa. 

For the first few months after the cord falls, the full 
bath may best be given by immersion. A morning hour 
should be chosen midway between feedings. The tem- 
perature of the water should be 98° F. by the bath ther- 
mometer ; that o£the room, 75° F. The least chilling is 
injurious. 

The duration of the bath should not exceed five minutes. 
From the standpoint of asepsis a soft, fresh-boiled cheese- 
cloth is preferable to a sea sponge. Only a bland, mildly 
alkaline soap (castile) should be used, and little of that. 
Special attention should be given to the scalp. The full 
bath is repeated daily in the summer, daily or every other 
day in the colder months. Parts of the body exposed to 
soiling must be cleansed as often as soiled. 

In puny and anaemic children the full bath is best post- 
poned for several hours or days. A partial sponging, or 
anointing daily with sweet oil or vaselin, may be substi- 
tuted. Infant powder is generally unnecessary. 

Navel Dressing. — The stump of the navel cord is 
dressed with dry sterile absorbent cotton ; turn to the left 
side to avoid injurious pressure on the liver, and retain by 
a loose abdominal binder. Rapid desiccation is the chief 
reliance for preventing putrefactive changes in the stump, 
and the dressing should be ordered accordingly. Powders 



188 ESSENTIALS OF OBSTETRICS. 

tend to hinder the drying and are best omitted. Bathing 
with strong alcohol and saturating the cotton with the 
same at the first dressing promotes desiccation. 

The dressing should be renewed after each bath. After 
the first bath, anointing with sweet oil may be substi- 
tuted for bathing till the cord falls. This usually occurs 
about the fifth day. 

It is imperative that the navel wound be kept surgi- 
cally clean. Septic infection of the navel may result in 
umbilical phlebitis, pyemia and death. 

Clothing. — For the first half year or more the follow- 
ing is recommended : 

1. Napkin of cotton diaper. 

2. An undershirt of the softest silk and wool, without 
sleeves, and opening in front. 

3. A fine flannel princesse dress with high neck and 
long sleeves, opening in front, and about twenty-five 
inches in length. 

4. A muslin slip of similar style. 

5. Woollen socks. 

During the night the socks may be removed and the 
muslin and the flannel slip be replaced with a light flannel 
night-dress. 

The belly-band and all bands in the clothing should be 
loose enough to admit two or three fingers underneath 
them. The belly-band should be discarded after the 
navel heals. In all seasons the skin should be protected 
with woollen undergarments and the extremities should 
be as warmly covered as other parts of the body are. 
No garment ought to be worn till laundered. 

Nursing. — The child is put to the breast after the 
mother has recovered from the shock of labor, usually 



PHYSIOLOGY OF THE PUERPERAL STATE. 189 

within from eight to twelve hours. Ten to fifteen 
minutes may suffice for each nursing. 

The usual frequency is once in four hours for a day or 
two, then every two hours. The milk becomes too rich 
with too frequent nursing, too thin with too long intervals. 
One interval in the night is lengthened to four or six 
hours. It is well to wake the child, if necessary, on the 
hour. The intervals should be extended to three hours 
by the time the child is three months old. As a rule, one 
or more artificial feedings daily will be required after the 
seventh or eighth month. 

Wet-nursing. — A good wet-nurse should be of mature 
age, below thirty-five, and preferably a multigravida. 
Her child ought to be of the same age as the foster child 
within one or two months. A menstruating woman is 
sometimes unsuitable, a pregnant one always. Sound 
physical and mental health is indispensable. She should 
be examined especially for tuberculosis, syphilis and other 
contagious diseases. The breasts should be of somewhat 
conical form, well developed, with prominent veins and 
well-formed and healthy nipples. The condition of the 
nurse's child speaks for the quantity and quality of her 
milk. 

Weaning. — The time for weaning, as a rule, is after the 
child has cut eight teeth, except when that period falls in 
the hot months. 

Evacuations of the Bowels and Bladder. — In 
health the number of bowel movements is from two to 
four daily. Urination is repeated every one to four 
hours. 

Sleep.— The newborn infant requires eighteen to twenty 
hours' sleep out of the twenty-four. 



190 ESSENTIALS OF OBSTETRICS. 

Artificial Feeding and Infant Dietary. 
First Twelve Months. 

Cow's milk should be the basis of the substitute food 
for at least the first year and a half of life. 

Mixed dairy milk is better than oue cow's milk be- 
cause of more nearly constant quality. 

The milk should be fresh and free from impurities. 
Uncleauliness, of itself poisonous, greatly impairs the 
keeping qualities of the milk. 1 

Sterilizing by heat destroys the germ content and re- 
tards fermentative changes; it does not destroy the products 
of fermentation. 

Heating to high temperatures impairs the nutritive 
value of the milk. Heating to 150° F. for twenty min- 
utes works a minimum of injury and is advisable when 
the cleanliness of the milk cannot be trusted and espe- 
cially during the hot months. 

Milk that is collected and handled with strict cleanli- 
ness, that is chilled below 60° F. within a few minutes 
after milking and is kept so needs no sterilizing. 

Such milk may be had in some of the larger cities from 
dairies especially conducted in the interest of infant 
feeding. 2 

Modification of Cow's Milk. 
The proportions of the principal nutritive ingredients 
in human and in cow's milk are approximately as fol- 
lows : 

1 Tablets for testing the freshness of milk may be had of the drug- 
gists or of the Cereo Company, Tappan, X. Y. 

2 The Walker-Gordon Company, New York City, the Certified 
Milk Co., New Jersey. 



PHYSIOLOGY OF THE rUERPERAL STATE. 191 

Human milk : Proteids 1 to 2 per cent., fat 3 to 4 per 
cent., sugar 7 per cent. 

Cow's milk : Proteids 4 per cent., fat 4 per cent., 
sugar 4 per cent. 

Ratio of Proteids to Fat — The proportion of proteids 
to fat in the substitute food should be about as follows : 

First four months : 1 : 3. 

Next six months (to end of tenth) 1 : 2. 

Subsequently nearly or quite 1:1, whole milk. 

How to obtain milk containing any required proportion 
of proteids and fat is obvious from the following facts : 

The milk is bottled at the dairy. The cream will all 
have risen to the upper third of the bottle after standing 
four hours on ice. Usually the milk will be found to 
have creamed fully when delivered, the line of demarka- 
tion between cream and under milk being plainly visible. 

The upper third of a quart bottleful of milk after 
creaming (about ten ounces) will contain 12 per cent, of 
fat (4x3 = 12). 

The upper half, 8 per cent, of fat (4 x 2 = 8). 

The mixture of milk and cream from the top of the 
bottle is termed top-milk. 

The percentage of fat in any other top-milk may 
readily be computed. 1 Ten-ounce and sixteen-ounce top- 
milk are most used. 

The percentage of proteids and of sugar is the same 
in all top-milk as in the whole milk. 

The top-milk is best removed by ladling it off with a 
small ladle or dipper, 2 or by syphoning off the under milk. 

1 The foregoing figures while not exact are sufficiently so for practi- 
cal purposes. 

2 A one-ounce dipper specially devised for the purpose by Dr. 
Henry Dwight Chapin may be had of the Cereo Co., Tappan, IS". Y. 



192 ESSENTIALS OF OBSTETRICS. 

Diluents. — The strength of the food is regulated by dilu- 
tion, the extent of which at different weeks of age is shown 
in the formulas on pp. 193-4 and in the table on p. 197. 

The diluent may be sterile water, dextrinized gruel or 
whey. 

Gruel or whey is generally the best diluent since it 
prevents the casein from forming tough curds in the 
child's stomach. 

Dextrinized Gruel is prepared as follows : A table- 
spoonful of barley, wheat or rice flour is rubbed to a 
paste with cold water and boiled for 20 minutes in a pint 
of water. After cooling to 100° F. a teaspoonful of 
cereo or of Forbe's diastase is added to the gruel which 
is allowed to stand for ten minutes. 1 

Sugar. — To bring the percentage of sugar up to the 
standard of human milk, milk sugar is added. It is 
convenient to remember that one ounce (about two and 
a half tablespoonfuls) of milk sugar to twenty ounces of 
mixed food adds 5 per cent, of sugar. 

Alkalinity. — Since cow's milk is generally acid, while 
human milk is alkaline, 5 per cent, of lime water (1 
ounce to 20 of the mixed food) is added. 

Whey. — Whey is prepared by adding one drachm of 
essence of pepsin (Fairchild), or one or two grains of 
scale pepsin to a pint of milk at a temperature of 115° 
F. After the curd separates the whey is strained off 
through two or three thicknesses of cheesecloth or 
through a wire gauge strainer. 

Whey contains about 1 per cent, proteids, .22 per cent, 
of fat and about 4 per cent, of sugar. 

1 Dextrinizing at a temperature above 100° F. causes an unpleasant 
taste of malt. 



PHYSIOLOGY OF THE PUERPERAL STATE. 193 

If the curd is stirred before straining the percentage of 
fat is raised to about 2 per cent. 

The proteid strength may be increased by adding white 
of egg. The white of one egg of medium size added to a 
pint of food adds about 1 per cent, of proteids. 

In feeble digestion whey may be used for a few days to 
the exclusion of other foods. As a diluent it yields a fine 
coagulum and has the advantage that its proteids are easily 
digestible. The proteids of cow's milk are chiefly (|) 
casein, which is difficult of digestion. 1 By the use of 
whey it is possible to raise the percentage of proteids to 
a limited extent, without impairing the digestibility of 
the food. The whey should be heated to 150° F. to kill 
the ferment before mixing with the top milk, otherwise 
the top milk will be curdled. 

The following formulas may be found convenient for 
general guidance in regulating the strength of the 
feeding : 

Food Formulas. 

For a Newborn Infant. 

Ten-ounce top-milk ..... 2 ounces. 

Sterilized water or sterilized gruel . . 14 " 

Milk sugar (two and a half tablespoonfuls) . 1 ounce. 
Lime water, about . . . . . . f " 

Latter Part of Third or Fourth Month. 

Ten-ounce top-milk 10 ounces. 

Dextrinized gruel or sterilized water . . 20 " 

Milk sugar 1J ounce. 

Lime water 1J " 

^he proteids of human milk are only one-third casein. The re- 
maining two-thirds are easily digestible proteids. 
13 



194 



ESSENTIALS OF OBSTETRICS. 



Beginning of Fourth 
Sixteen-ounce top-milk . 
Dextrinized gruel . 
Milk sugar .... 
Lime water .... 



Fifth Month. 



8 ounces. 
24 " 
lh ounce. 
1* " 



Latter Part of Tenth Month. 

Sixteen-ounce top-milk ..... 32 

Dextrinized gruel 16 

Milk sugar 2 

Lime water 2 

Tenth to Twelfth Month. 

Whole milk 32 

Gruel plain or dextrinized . . . . 16 

Milk sugar 2 

Lime water 2 




18 ounces. 
3 
f ounce. 
1 " 
20 ounces. 
5 
f "ounce. 
1 " 



Whey Mixtures. 
No. 1. Whey. 

Cream (six-ounce top-milk). 

Sugar (two tablespoonfuls) . 

Lime water . 
No. 2. Whey . . 

Cream (six-ounce top-milk). 

(Sugar two tablespoonfuls) 

Lime water . 

Bartley's Formula. — The top fourth is removed from 
the quart bottle of milk after creaming. Whey is pre- 
pared from the remaining three-fourths and, after heat- 
ing to 150° F. and cooling, is mixed with top-milk. 
Milk sugar is add to the required percentage. 

Bottling. — The food should be prepared soon after the 
milk is delivered and distributed in nursing bottles each 
holding enough for a single feeding. The bottles are 
kept on ice till required for use. 

The food is fed at a temperature of 98° F., directly from 
the bottle in which it was prepared, a rubber nipple be- 
ing slipped over the neck of the bottle. 



PHYSIOLOGY OF THE PUERPERAL STATE. 195 

Bottles and nipples are cleaned after nursing, and steri- 
lized by boiling 20 minutes immediately before refilling. 

Regulation of the Strength and Quantity of Food. 
— Care should be taken to increase the strength of the 
food by lessening the proportion of the diluent, as 
rapidly as the child's digestion will permit. The stomach 
capacity at birth is approximately T ^ the body-weight 
of the child. As a rule it is an ounce for the first week 
and increases by a drachm and a half per week during the 
first five or six months. After that age the rate of in- 
crease is somewhat smaller. 

The weekly weight of the child is a good guide in regu- 
lating the feeding. As already stated, a properly nour- 
ished child gains at least five ounces weekly during the 
first five months. For the remainder of the first year the 
average gain is about a pound per month. The birth- 
weight is doubled at five months and trebled at fifteen. 

A watchful supervision must constantly be exercised in 
adapting the food to the requirements of individual cases. 

The following table is intended for general guidance in 
regulating the amount and frequency of feeding. 



Amoi 


int and Frequency of Feeding. 




Age. 


Intervals 

of 
feeding. 1 


Amount at 

each 
feeding. 2 


Number of 

daily 

feedings. 


First day 




1 drachm. 
£ ounce. 
1 

1*7 ounces. 
2| « 
3* " 
5* » 
6| « 
9 


10 




2 < 
2 < 

2 < 
2* < 

3 < 
3 < 
3 ' 
3* < 




10 


Third day 


10 




10 




8 


Three months 


7 


Six " 


6 


^ine " 


6 


Twelve " 


5 









1 Lengthen one interval in the night to four or six hours. 

2 By measuring-glass. 



196 ESSENTIALS OF OBSTETRICS. 

Small or feeble children should be fed more fre- 
quently and in smaller quantities, robust children in 
larger quantities. 

Milk Laboratories. 

Laboratories for the modification of cows' milk for 
infant feeding have been established in several of the larger 
cities of the country. The physician writes a prescription 
for the food mixture very much as he does for medicine. 
The proportions for the essential ingredients in the formula, 
proteids, fat, and sugar are adjusted to the requirements 
of the individual case. The food mixture supplied daily 
from the laboratory is prepared according to the pre- 
scription, which is modified by the physician as occasion 
requires. 

The following formula, 1 suitable for a healthy, full term 
infant, one week old, illustrates the method of prescribing. 

R.— Proteids . . 0.50 

Fat 1.50 

Milk sugar 5.00 

Lime water . . . . . . . . 5.00 

Mix. Sterilize at 167° F. 

Send 10 bottles of 1^ ounce each. 

In weak albuminoid digestion the proportion of pro- 
teid is reduced to the minimum, 0.20 per cent., and gradu- 
ally increased to the point of tolerance. A like modi- 
fication is prescribed in the case of the fat or the sugar, 
should either of these and not the proteid element be 
found to be the source of the digestive disorder. 

The following table shows the quantities of food and 

the percentages of proteid, fat, sugar, etc., required at 

1 The numerals in the formula represent percentages. It is under- 
stood that the rest of the 100 parts is made up with water. 



PHYSIOLOGY OF THE PUERPERAL STATE. 197 



different periods of the 
experience of the milk 
Boston. 



first year, as deduced from the 
laboratories of New York and 



Amount and Strength of Food. 



Age. 



Premature infants. 

Full term healthy infants. 

1 week 

2 weeks 

3 " 

to 6 weeks 



4 
6 
8 
16 
24 
32 
34 
36 
40 
44 
48 



16 

; 24 

32 

34 
36 
40 
44 
48 
52 



Stomach 


Proteid. 


Fat. 




capacity. 








2-6 drms 


0.20-0.50 


1.00-1.50 


3.00-5.00 


1 oz. 


0.50 


1.50 


5.00 


H " 


0.75 


2.00 


5.00 


2 " 


1.00 


2.50 


6.00 


U " 


1.00 


3.00 


6.00 


3i " 


1.00 


3.50 


-6.50 


4 " 


1.50 


3.50 


6.50 


4J « 


1.50 


4.00 


7.00 


5 " 


2.00 


4.00 


7.00 


z.1 u 


2.00 


4.00 


7.00 


6 " 


2.25 


4.00 


7.00 


6| " 


2.50 


4.00 


6.50 


7 " 


3.00 


4.00 


5.00 


7* " 


3.50 


4.00 


4.50 


8 " 


4.00 


4.00 


4.00 



Lime- 
water. 

5.00 

5.00 
5.00 
5.00 
5.00 
5.00 
5.00 
5.00 
5.00 
5.00 
5.00 
5.00 
5.00 
5.00 
5.00 



Twelve to Eighteen Ifonths. 

The child may take four or five feedings daily of whole 
milk with wheat, barley, rice or oatmeal gruel in the pro- 
portion of one-third the mixture. The gruel may be some- 
what thicker than that used in the preceding months. 
Two or three ounces of uncooked beef-juice, moderately 
seasoned, may be given daily ; it may be mixed with 
the milk or be given separately. It must be prepared at 
least twice a day and kept on ice. Care must be taken 
that the beef is fresh. 

After the child has sixteen teeth the simpler kinds of 
food requiring mastication may be added, such as oatmeal 
and milk, or wheaten grits, thoroughly cooked, or stale 
bread and milk. Scraped beef or soft-boiled eggs may be 
allowed two or three times weekly. 



198 ESSENTIALS OF OBSTETRICS. 

Eighteen Months to Two Years. 

The number of feedings may be four or five daily. A 
little fine cut meat, such as tender beef, lamb or chicken, 
may be added to the mid-day meal if the child is robust. 

Milk should be the chief reliance for feeding till the 
child has all its teeth and may constitute a part of its food 
for several years longer. Milk, beef-juice and the fari- 
naceous preparations above mentioned afford an ample 
dietary for the entire period of infancy. Proprietary 
foods for infants are not to be recommended. 

DISORDERS OF THE NEWBORN INFANT. 

Constipation. 

Treatment. — Regulate the digesting and the feeding. 
Enough cream may be added to the food to raise the pro- 
portion of fat to 4, 5 or 6 per cent. This alone frequently 
overcomes the constipation in bottle-fed infants. Even a 
moderate excess of fat, however, is not in all cases well 
borne. 

Suitable laxatives are the following : 

R. — Sodii pkospliatis . . . . . gr. x. 

Sacchari lactis gr. x. — M. 

This may be given at one dose in a teaspoonful or two 
of water or of syrup of manna. 

R. — Ext. senna? fluid, deodorat. (N. F.) . . gss. 

Potassii et sodii tartratis 3J- 

Glycerini gss. 

Aquse ad giv. — M. 

Dose, a teaspoonful, p. r. n. 

Phillips' milk of magnesia is an eligible laxative for 
infants. The dose is a teaspoonful. 



PHYSIOLOGY OF THE PUERPERAL STATE. 199 

Useful rectal measures are the injection of equal parts 
of glycerin aud water, 5\j, sweet oil, 5iv, or warm water, 
5j. The use of a suppository of soap or cacao butter or 
a glycerin or gluten suppository generally provokes im- 
mediate action of the bowels. Yet glycerin suppositories 
may prove too irritating to the rectum for continued use. 

Indigestion. 

Symptoms. — Flatulence, sour, green and curdy stools, 
vomiting an hour or more after nursing or feeding, rest- 
lessness, disturbed sleep, colic, failure of the normal gain 
in weight. 

Treatment. — The treatment should consist mainly in 
the regulation of the nursing or feeding. The food is 
almost invariably the source of the trouble. Look to 
the health and habits of the mother. It is sometimes 
useful to dilute the mother's milk by giving the child a 
teaspoonful or two of warm water with the nursing. In 
acute indigestion all feeding should be stopped for sev- 
eral hours. For a time longer whey or dextrinized 
gruel may be substituted for milk. Sometimes the first 
thing needed is to relieve the stomach of its contents by 
lavage. Four to five J^-grain doses of calomel given 
at intervals of a half hour may be useful. 

Colic. 

Treatment. — Remove the cause, which is to be found 
in faulty digestion, by regulating the feeding. 

For the pain chloral is almost a sovereign remedy. The 
dose is gr. j in water, 5j, or in syrup of vanilla and water, 
aa 5ss, repeated once to three times daily, p. r. n. ; milk 
of asafetida 5j by the mouth or §j per rectum is generally 



200 ESSENTIALS OF OBSTETRICS 

effective ; warm applications to the abdomen and warm 
rectal injections, Sj, are useful palliatives. The curative 
treatment must consist mainly of measures addressed to 
the digestive disorder. 

Diarrhoea. 
Treatment. — The cause is generally indigestion. All 
feeding should be suspended for several hours. No milk 
should be allowed for 24 or 48 hours. White of egg or 
dextrinized gruel may be substituted. The strength of the 
gruel for this purpose may be 4 tablespoonfuls to the pint. 
Milk feeding when resumed must be begun cautiously. 
A mild laxative, castor oil or calomel or both, may be in- 
dicated to remove irritating material ; then bismuth sub- 
nitrate, gr. x, may be given every one or two hours. Should 
this fail add camphorated tincture of opium, Tttiij to x, to 
each dose of the bismuth. Calomel is especially useful in 
case of vomiting ; opium for pain, frequent stools or tenes- 
mus. Number of stools should not be reduced below 4 
daily. Irrigation of the colon once or twice daily with 
normal salt solution is indicated only in the presence of 
putrescible accumulations. 

Thrush. 

Symptoms. — The mucous membrane of the mouth is 
studded with white patches, due to the presence of a 
fungus. The patches resemble milk-curds in appearance, 
but are distinguished from them by their firm adhesion 
and by the detection of the mycelia and spores of the 
parasite under the microscope. 

Treatment. — To destroy the fungus sop the patches 
every two hours with a saturated solution of boric acid 



PHYSIOLOGY OF THE PUERPERAL STATE. 201 

or with a solution of sodium sulphite, one drachm to the 
ounce. For the stomatitis which persists after destruc- 
tion of the fungus use a half-saturated solution of potassic 
chlorate, or better, as being less toxic, sodic chlorate, as a 
mouth-wash. The child must not be permitted to swal- 
low any of these solutions. The accompanying gastro- 
intestinal disorders are to be treated as in other cases. 

Intertrigo. 
Treatment. — Keep the parts clean, with care to do 
no mechanical violence to the skin by too much friction. 
Use as an infant powder lycopodium and oxide of zinc, 
equal parts, dusted on the affected surfaces after cleans- 
ing, p. r. n. Talcum powder is a useful application. 

Cephalhematoma . 

Cephalhematoma is an extravasation of blood, usually 
between the pericranium and the cranial bones ; rarely it 
occurs internally. After a few days a hard ridge de- 
velops at the margin of the tumor owing to periosteal in- 
flammation. 

Its situation is most frequently over one parietal bone ; 
exceptionally it is the site of the caput succedaneum. 

Prognosis. — In the internal form the prognosis is 
grave if .cerebral symptoms develop. The external va- 
riety, as a rule, terminates in subsidence of the tumor in 
about three months. 

Treatment. — If the swelling grows it may be strapped 
firmly after shaving the head. If pus forms early in- 
cision is indicated. Otherwise no treatment is considered 
advisable by most authorities. The writer has practiced 
the evacuation of the blood within a few days after birth 



202 ESSENTIALS OF OBSTETRICS. 

by a small incision. The tumor must first be shaved and 
the strictest asepsis be observed. A firm antiseptic com- 
press is applied and held in place with a roller bandage. 
When the incision has been delayed for one or two weeks 
a longer incision may be required owing to the presence 
of blood-clots. Should the hemorrhage persist after 
opening the tumor it may be controlled by pressure. 

Preputial Adhesion. 
In male children the adhesion of the foreskin to the 
glans which is usually physiological in newborn children, 
may cause irritability of the bladder and other reflex dis- 
turbances. In such cases the preputial orifice should be 
dilated very gently and the adhesion broken up till the 
foreskin can be fully retracted. Nicking the prepuce 
with scissors in the median line on the dorsum may be 
required to permit retraction. Drawing back the prepuce, 
it is liberated from the glans by the aid of a smooth, 
blunt, stiff probe ; a dressing of vaselin or of bismuth 
powder together with daily retraction will prevent re-ad- 
hesion. 

Icterus. 

Icterus occurs in a large proportion of newborn infants. 
It begins from the first to the fifth day after birth, most 
frequently on the third or fourth. It is observed most 
frequently in premature and feeble infants and after diffi- 
cult labor. There are two forms, the mild and the grave. 
Both are due to resorption of bile. 

In the mild form the conjunctivae and the urine are 
not stained. In the grave form the conjunctivae and the 
urine are stained and the stools are clay-colored. This form 
may be due to general sepsis or to serious organic disease. 



PHYSIOLOGY OF THE PUERPERAL STATE. 203 

Treatment. — As a rale none is required. In persistent 
cases attention to the digestion, keeping the bowels open 
by enemata, or, if need be, by the use of a mild laxative, 
as sodium phosphate, combined if necessary with occa- 
sional small doses of calomel, constitute the treat- 
ment. 

In persistent icterus with increasing discoloration, and 
especially with the presence of sepsis and high tempera- 
ture treatment is generally futile. 

Ophthalmia. 

Cause. — The cause is infection usually from the genital 
tract of the mother. The gonococcus of Neisser is the 
infecting organism in more than one-third. The ordinary 
pyogenic bacteria and the Loeffler bacillus are often the 
active agents. It generally begins on or before the third 
day. 

Prognosis. — The prognosis for the sight is grave in the 
absence of timely treatment. Most serious is a mixed in- 
fection with gonococcus and streptococcus or with strep- 
tococcus and Loeffler's bacillus. A bacteriological diagnosis 
is important with relation to prognosis. In this country 
thirty-two per cent, of all cases of total blindness in 
asylums are said to be due to this cause. Almost without 
exception under skilfully conducted management the sup- 
puration is promptly controlled and the sight is not im- 
paired permanently. 

Treatment. Prophylactic. — The maternal passages 
should be disinfected before and during labor in case of 
gonorrheal secretion. The child's eyes should be cleansed 
immediately after the head is born. Instil one or two 
drops of a two per cent, solution of nitrate of silver, or 



204 ESSENTIALS OF OBSTETRICS. 

a ten per cent, protargol solution into each con- 
junctival sac shortly after birth. The latter is now gen- 
erally preferred. The prophylactic use of the silver so- 
lution is the rule in hospital practice. The eyes of every 
child are treated with solution within a few minutes after 
birth. A similar precaution may well be observed in 
private practice. It should never be omitted when the 
mother is known to be the subject of leucorrhoeal dis- 
charges. When properly employed the immunity is 
practically absolute. Should the use of the silver solu- 
tion be followed by much serous oozing the latter may be 
relieved promptly by a single application to the conjunc- 
tivae of a one-grain solution of atropine, one drop in each 
eye. 

Curative. — At the onset of the inflammation cold ice- 
water compresses, renewed every few minutes, are useful 
in the absence of corneal complications. 

Cleansing. — Removal of the pus every hour or two by 
irrigating or bathing with a warm saturated boric-acid 
solution is essential. 

Silver Nitrate or Protargol Solution. — After free dis- 
charge is established brush the conjunctival surfaces after 
cleansing once or twice daily with a two to four per cent, 
aqueous solution of nitrate of silver or a ten per cent, 
aqueous solution of protargol freshly made. This is 
continued till the discharge loses its purulent charac- 
ter. Frequent cleansing with the boric-acid solution 
must still be practiced till all discharge ceases. Anoint- 
ing the edges of the lids with vaselin favors drainage 
by preventing the lids from becoming glued together. 
The nurse should be drilled in the method of manipu- 
lating. 



PHYSIOLOGY OF THE PUERPERAL STATE. 205 
As a rule the advice of an oculist should be had. 1 

I Inb il ica I Infection . 

The cause is uncleanliness in the care of the umbilical 
Wound. The infecting organism is most frequently the 
streptococcus. The septic process may result in a mere 
local ulcer or in umbilical phlebitis and septicaemia. In 
the latter event the termination is fatal usually by con- 
vulsions. Pus may be present in the umbilical vessels 
from infection through the navel even when the wound 
has healed promptly. Cellulitis of the abdominal walls 
and peritonitis are frequently observed. Septic processes 
in remote organs are common complications. 

Treatment. — In local sepsis frequent antiseptic cleans- 
ing of the wound surface and dressing with aristol, bis- 
muth powder or iodoform and bismuth suffice. The 
peroxide of hydrogen is a good antiseptic for disinfecting 
the wound surface. It is non-poisonous and practically 
non-irritant. Inunctions of quinine and the use of 
stimulants by the stomach help to increase the resisting 
power. In systemic infection treatment is futile. 

Tetanus Neo nato ) ■ urn . 

The disease begins toward the end of the first week. 
The cause is infection, generally of the navel, with the 
tetanus bacillus. 

The symptoms are those of surgical tetanus. The ter- 
mination is almost invariably fatal within two or three 
days. 

1 In New York State a midwife or nurse who may be cognizant of any 
inflammatory affection in the eyes of an infant under her care is re- 
quired by law to report the fact in writing, within six hours, to the 
Health Officer, or to some legally qualified practitioner of medicine in 
the city, town or district in which the parents reside. 



206 ESSENTIALS OF OBSTETRICS. 

Treatment. — As far as possible all sources of periph- 
eral irritation should be removed. Feeding is main- 
tained through the nostrils, using pre-digested milk, or, 
this failing, by rectal injections. In feeding through the 
nostrils the food is poured from a special narrow pointed 
spoon. The drug treatment consists in the use of potas- 
sium bromide, gr. iv every two to four hours, or of 
chloral, grain j every hour, p. r. n. These remedies must 
be given by a stomach -tube or by a rectal tube. Sulpho- 
nal, gr. iij every two hours, by the rectum, has been used 
with success. The value of the serum treatment is still 
sub judiee. 

Umbilica I Hemorrhage. 

Umbilical hemorrhage may proceed from faulty ligation 
of the cord, syphilis, sepsis, acute fatty degeneration with 
hemoglobinuria or hemophilia. The hemorrhage usually 
begins within a week or a little more after birth. Eighty 
per cent, of the children die. 

Treatment. — In simple cases re-ligate the cord and 
apply a compress, or lift the umbilicus, transfix with a 
harelip-pin and apply a figure-of-eight ligature. In cases 
dependent on a dyscrasia treatment is generally futile. 

Mastitis. 
Swelling of the breasts is frequently observed in new- 
born children during the first week. As a rule it calls 
for no treatment. If pus form, which is very rarely the 
case, it should be evacuated. 

A Bloody Genital Discharge. 
A bloody genital discharge is sometimes observed in 
female children the first few days after birth ; no treat- 
ment is required. 



CHAPTER V. 
PATHOLOGY OF PREGNANCY. 

DISEASES OF THE DECIDUJE. 

Acute Endometritis. — Acute endometritis may be 
present in the course of acute febrile disease. It is often 
attended with hemorrhage and frequently results in abor- 
tion. 

Chronic Diffuse Endometritis. — The causation is not 
fully understood. The anatomical changes in the decidua 
are mainly hypertrophic. It occasionally gives rise to 
abortion. 

Catarrhal Endometritis. — Catarrhal endometritis is 
attended with a discharge of watery mucus from the 
uterus — hydrorrhea gravidarum ; it is most common in 
the later months of pregnancy. Sometimes the fluid col- 
lects between the chorion and the decidua and is dis- 
charged in gushes. Rarely the uterus becomes excessively 
distended by the accumulated fluid. The inflammation 
affects most frequently the vera ; it may also involve the 
reflexa. It is attended with hypertrophy of the connec- 
tive tissue and of the glandular elements. Exceptionally 
it terminates in abortion or premature labor. 

In this condition the hyperplasia of the uterine mucosa 
which is normal to the early months of pregnancy, is ex- 
aggerated and is continued to the later months of gesta- 
tion. It affects all the elements of the decidua and re- 



208 ESSENTIALS OF OBSTETRICS. 

suits in a greatly increased thickness of this structure. 
Hemorrhage frequently occurs in the decidua. Cysts have 
been observed. The cause is a preexisting endometritis 
which may be of the septic, syphilitic or gonorrheal 
type. 

When the process is rapidly developed it is attended with 
hemorrhages into the decidua or with partial separation of 
that structure ; abortion or premature labor is the rule. 

Debility and anaemia frequently result from hydrorrhea. 
The discharges are to be distinguished from liquor amnii, 
from urine and from leucorrhoeal secretions. 

Treatment. — The treatment is. to be addressed mainly 
to the resulting debility and anaemia. The arsenate of 
iron or other hematinic and general tonics are indicated. 

Cystic Endometritis is distinguished by the formation 
of retention cysts due to obstruction of the gland-ducts 
by proliferation of interglandular connective tissue. Here, 
too, there is hydrorrhcea. 

Polypoid Endometritis is rarely met with. It is char- 
acterized by polypoid growths upon the ovular surface of 
the decidua, in addition to the lesions of simple diffuse 
endometritis. The pathological changes are generally 
limited to the decidua vera. Rarely, however, they in- 
volve the serotina. The placental villi may undergo hy- 
pertrophy or myxomatous degeneration. Death of the 
foetus and abortion usually result. 

ANOMALIES OF THE AMNION AND THE LIQUOR 

AMNII. 

Oligohydramnios. — The quantity of amnial liquor at 

term is normally about two pints. Oligohydramnios is a 

deficiency of liquor amnii. Extreme scantiness of the 



PATHOLOGY OF PBEGNANCY. 209 

aninial liquor may be attended with adhesions between 
the amnion and the foetus and with the formation of am- 
niotic bands. Intra-uterine amputation of foetal extremi- 
ties and other developmental faults sometimes result from 
these amniotic bands. Harelip, cleft palate, navel-cord 
hernia, and spina bifida are frequently produced by this 
agency. Oligohydramnios is one of the causes of club-foot. 

Hydramnios or Polyhydramnios may be defined as 
an excess of liquor amnii over 4 pints. In extreme cases 
the quantity may reach 30 to 50 pints. 

Polyhydramnios occurs much more frequently in mul- 
tiparas than in primiparse. It is usually present to some 
degree in twin pregnancies. Excess of liquor amnii may 
exist in one foetal sac and deficiency in the other. Great 
excess of the amnial liquor is often attended with mal- 
formation of the foetus. It begins most frequently in the 
latter half of pregnancy and is observed once in about 
three hundred pregnancies. 

Causes. — Among the causes assigned are maternal ana- 
sarca, abnormal persistence of the vasa propria (a capil- 
lary network of the subplacental chorion immediately 
underlying the amnion, and which is normally present in 
the early months of gestation), excessive secretion of urine 
by the foetus, exudation of the foetal skin, amniotitis, 
decidual disease, deficient resorption of liquor amnii. 
Fcetal syphilis is a possible cause. 

Diagnosis. — The more important physical signs are ex- 
cessive size and permanent tension of the uterine tumor, 
suprapubic oedema, preternatural mobility of the foetus. 
In extreme amniotic distention the cervix is obliterated. 
Hydramnois is distinguished from ascites, ovarian cyst 
and twins, by palpation and auscultation of the tumor and 
14 



210 ESSENTIALS OF OBSTETRICS. 

by the history. The differential diagnosis will be found 
discussed under the topics referred to. 

Prognosis. — The prognosis is unfavorable to the child, 
owing to premature birth, dropsical affections, malforma- 
tions and malpresentation, which are common in hydram- 
nios. The foetal mortality is 25 per cent. For the mother 
the prognosis is generally good. 

Treatment. — In case of alarming symptoms from 
over-distention, puncture of the membranes, with care to 
guard against syncope from too rapid escape of the liquor 
amnii, is permissible. On the birth of the child precau- 
tions may be needed against post-partum hemorrhage. 
Special care must be taken to promote retraction of the 
uterus after delivery. 

DISEASE OF THE CHORION. 

Cystic Degeneration of the Chorion, Vesicular Mole, 
Hydatidiform Mole, may be denned as " an hypertrophy 
and myxomatous degeneration of the chorial villi, at- 
tended with the formation of cysts. " The cysts vary in 
size from that of a millet seed to a grape — they may reach 
the size of a hen's egg. Each cyst springs from another 
and not from a common stalk. They may be many thou- 
sand in number and the total mass as large as the moth- 
er's head. Very rarely the villi perforate the uterine 
wall, leading to rupture of the uterus and peritonitis. 
The cyst content is a clear watery fluid containing albu- 
min and mucin. The degeneration begins most frequently 
in the very first weeks of gestation. In twin pregnancies 
one or both ova may be affected. 

It is met with most frequently in women who have 
borne full term children, sometimes in more than one 



PATHOLOGY OF PREGNANCY. 211 

pregnancy in the same individual. It occurs once in 
something more than two thousand pregnancies. 

Etiology. — Of the etiology little is known. The cause 
apparently resides in the ovum. Endometritis, syphilis 
and absence or deficiency of allantoic vessels, commonly 
assigned as causes, probably have no part in the etiology. 

Diagnostic Signs. — Signs of pregnancy : 

Abdominal enlargement out of proportion to the stage 
of gestation ; the uterus is too large the first three 
months, later it is sometimes too small. 

Absence of ballottement, of the foetal heart, of foetal 
parts and of foetal movement. 

Uterus usually doughy. 

Sero-sanguineous discharge. 

Expulsion of cysts, rarely noted. 

Detection of the cysts by direct exploration of the 
uterine cavity. The disease is rarely recognized till after 
the third month. 

Prognosis. — The maternal mortality is 10 to 15 per 
cent. Immediate causes of death are hemorrhage, sepsis 
and rupture of the uterus. Except in rare cases of par- 
tial degeneration the embryo invariably dies and disap- 
pears by absorption. The degenerated ovum may be re- 
tained for many months ; usually it is expelled before the 
sixth. 

Treatment. — If no evidence can be found that the foetus 
is living the uterus should be emptied. The cervix is to 
be dilated and the evacuation of the uterine cavity begun 
with the hand or dressing-forceps. This must be done 
cautiously, since the uterine wall is often extremely thin. 
Curettement is practiced after considerable retraction has 
taken place. The uterus is washed out with a hot, mild 



212 ESSENTIALS OF OBSTETRICS 

antiseptic douche and its cavity swabbed with tincture of 
iodine. Ergot is given, if required, to make the uterus 
contract. 

ANOMALIES OF THE PLACENTA. 

Placenta Membranacea. — A placenta membranacea is 
a broad, thin placenta with persistence of the villi over 
the entire surface of the chorion. Abnormal adhesion is 
common with this anomaly. 

Placenta Praevia. — The placenta is prsevia when its 
attachment encroaches upon that portion of the uterus 
which is subject to dilatation during the first stage of labor. 

Placenta Succenturiata. Subsidiary Placenta. — This 
term is applied to a wholly or partially independent pla- 
cental cotyledon. The anomaly is usually single, some- 
times multiple. 

Cysts of the placenta are of frequent occurrence. The 
cysts are small and are seated beneath the amnion. They 
are probably developed from the chorial villi. 

Syphilis. — The syphilitic placenta is larger and paler 
than normal, and yellowish in patches. In syphilis of 
paternal origin the foetal structures of the placenta are 
affected ; when the disease is of maternal origin the de- 
cidua is involved ; in the tertiary stage gummata are pres- 
ent. Syphilis of the placenta is always dangerous, and 
may be fatal, to the foetus. 

(Edema may be present in hydramnios, in occlusion of 
umbilical veins or in maternal anasarca. 

Apoplexy. — Extravasations of blood into the placenta 
may occur at one or several points. Hemorrhages in the 
early months of pregnancy occur near the foetal surface, I 
in the later months near the maternal surface of the pla- 
centa. The causes are placentitis, general infectious dis- 



PATHOLOGY OF PREGNANCY. 213 

eases, nephritis, pelvic congestion, traumatism. Exten- 
sive effusions of blood result in 'the death of the embryo 
or foetus and consequent abortion or premature labor. 
Small extravasations are generally tolerated with no ap- 
parent ill-result. Small blood-collections may be found 
partially organized, or may become fatty or calcareous. 

Myxomatous Degeneration usually involves only a 
part of the placenta. (See Vesicular Mole, page 210.) 

Fatty Degeneration may result from endometritis, 
placental hemorrhage or chronic inflammation of the 
placenta. Death of the foetus may ensue. 

Placentitis may affect the whole, rarely a portion 
only, of the placenta. Placental inflammation may result 
from endometritis existing at the time of conception, or 
from syphilis or acute sepsis. The normal placental 
structure is replaced by fibroid tissue. There are hyper- 
trophy and sclerosis of the decidua. Abnormal adhe- 
sions of the placenta are attributed to this cause. 

Calcareous Degeneration is common and is unim- 
portant. 

White Infarcts are very commonly observed in the 
placenta. They are dense whitish or yellowish masses 
varying in size from one to two or three centimeters in 
diameter. They are of no pathological importance when 
small and few in number. When numerous and exten- 
sive they may cause the death of the foetus. They have 
their origin in local degeneration of the decidua. 

ANOMALIES OF THE UMBILICAL CORD. 
Length. — Excessive length of cord may predispose to 
prolapse, to torsion, to knots, or to coils about the foetus 
and to obstruction in the funic vessels. A short cord 



214 ESSEXTIALS OF OBSTETRICS. 

may lead to premature separation of the placenta during 
labor. 

Excessive Torsion of the umbilical vessels may cause 
partial occlusion. It is sometimes accompanied with se- 
rous effusion into the peritoneal cavity of the foetus and 
with oedematous swelling of the cord. In most cases 
torsion of the cord itself is developed only after the 
death of the foetus. 

Knots occur rarely. They result from the passage of 
the foetus through a loop of the cord. They are seldom 
firm enough to endanger the foetus. 

Hernia. — Hernial protrusion of omentum or intestinal 
loops may take place into the cord. It results from im- 
perfect closure of the abdominal walls at the umbilicus, 
and is usually accompanied with other errors of foetal 
development. 

Cysts are frequently observed in the sheath of the cord. 
They are due to liquefaction of mucoid tissue or of blood 
extravasations. 

Coils about the foetus, especially the neck, are of fre- 
quent occurrence. Sometimes an arm or a leg is thus en- 
circled. Rarely is the circulation impeded either in the 
funis or the girdled member. Extensive coilings may 
give rise to the dangers of short cord. 

Coiling of the cord about the neck of the child some- 
times may be recognized during pregnancy by depressing 
the abdominal walls of the mother opposite the child's 
neck ; the foetal pulse-rate is retarded when the cord is 
pressed upon. 

The Insertion may be eccentric, marginal or velamen- 
tous. In the latter anomaly the vessels pass for a greater 
or less distance between the membranes to the edge of the 



PATHOLOGY OF PREGNANCY. 215 

placenta. As the vessels are more or less separated and 
unprotected they are liable to be torn during labor. Such 
an accident almost surely results in the death of the child 
unless it is born promptly. 

When the insertion of the cord is marginal the placenta 
is sometimes termed a battledore placenta. 

PATHOLOGY OF THE FCETUS. 
ANOMALIES OF DEVELOPMENT. 

The principal anomalies of foetal development are 
briefly the following r 1 

(a) Hemiteria. — Literally, half monstrosity. Under 
this head are included dwarfs and giants, microcephalia, 
sternal fissure, spina bifida, club-foot, supernumerary dig- 
its, double uterus, double vagina, supernumerary ribs, etc. 

(6) Heterotaxia. — Under this head are included trans- 
position of viscera, hernial protrusion, imperforate rectum, 
vagina, oesophagus, etc., persistent foramen ovale, persist- 
ent ductus venosus, persistent ductus arteriosus, etc., 
webbed fingers or toes, harelip, cleft palate, epispadias, 
hypospadias, hermaphrodism. 

(c) Teratism. 1. Eetromelic 31 ouster. — Having one or 
more aborted extremities. 

2. Symelic Monster. — Having its lower limbs partly or 
wholly united. 

3. Celosomatic Monster. — Having partial or complete 
eventration. 

4. Exencephalic Monster. — In this anomaly the brain 
is malformed and protruding from the cranial cavity. 

5. Pseudeneephalic Monster. — Here the cranial vault 
and the larger part of the brain are absent. 

1 In part'after Norris, 



216 ESSENTIALS OF OBSTETRICS. 

6. Anencephalic Monster. — The cranial vault and the 
entire brain are wanting. 

7. Cyclocephalie Monster. — A monster in which the 
nose is wanting and the eyes are partially fused into one. 

8. Otocephalic Monster. — The ears meet or are fused in 
the median line. 

9. Omphalositic Monster. — This monster is one of twins 
which has a parasitic existence in utero. Its nourishment 
is derived from the companion foetus, and it is incapable 
of living independently after the cord is divided. The 
anomaly owes its origin to the fact that the circulation of 
one foetus has overpowered and reversed that of its com- 
panion. 

10. Double Monster. — Two foetuses united. 
Varieties : — (a) Sternopagus, joined at the sternum ; 

(b) Ischiopagus, joined at the pelvis ; (c) Cephalopagus, 
joined at the head ; (d) Xiphopagus, joined at the xiphoid 
cartilage. 

Syncephalic. — The heads partly fused, the bodies sepa- 
rate. 

Monocephalic. — The heads completely fused, the bodies 
separate. 

Synsomatie. — The bodies are partially fused, the heads 
separate. 

Monosomatic. — The bodies are wholly fused, heads 
separate. 

Double Parasitic Monster. — One foetus is attached as a 
parasite to the other, or inserted or included in it. 

DISEASES OF THE FCETUS. 

The foetus is subject to many of the infectious and other 
general diseases of post-natal existence. Well-known ex- 






PATHOLOGY OF PREGNANCY. 217 

ainples are variola, typhoid fever, pneumonia, syphilis, 
scarlatina, measles, rachitis, valvular disease of the heart, 
serous effusions, etc. 

FGETAL DEATH. 

Diagnosis. — Signs of foetal death are : 
Recession of signs of pregnancy ; 
Uterus doughy ; 
Peptonuria ; 
Acetonuria ; 1 

Cervical temperature not above the vaginal ; 
Absence of foetal heart-tones ; 

Absence of active foetal movements — examine by ab- 
dominal palpation and by the bimanual ; 
Absence of the choc foetal ; 
Looseness and crepitation of cranial bones. 
Frequently the mother experiences periods of illness and 
a sense of weight in the abdomen. 

In most cases of suspected death of the foetus repeated 
examinations will be required to decide the question. The 
diagnosis of death of the ovum is especially difficult in the 
early months of development before the period when in the 
living foetus the heart can be heard or active movements 
felt. 

The recognized causes of intrauterine death, such as 
mechanical violence, maternal toxaemia or profound an- 
aemia, syphilis, etc., should be sought for. 

Habitual death of the foetus, in a great majority of cases, 
is the result of syphilis in one or both parents. The most 
important signs of foetal syphilis to be found by post- 
mortem dissection are osteochondritis, between the dia- 

! Test for acetone : a 1 : 2,000 solution of fuchsine yields a violet 
color in presence of acetone. 



218 ESSENTIALS OF OBSTETRICS. 

physis and epiphysis of the long bones, especially at the 
lower end of the femur, enlargement of the liver, often to 
one-twelfth or even one-eighth the body-weight, enlarge- 
ment of the spleen. 

Changes in the Foetus after Death in Utero. 

The dead foetus carried in utero undergoes either ab- 
sorption, mummification, maceration or putrefaction. 

Absorption. — This occurs usually when the foetus dies 
in the first two months of gestation. The embryo in 
course of a few days after its death becomes liquefied and 
absorbed. 

Fleshy Mole. — Sometimes when the ovum is carried in 
utero for a long period after the death and absorption of 
the embryo the uterine contents are reduced to a dense mass 
of placental structure and organized blood-clot known as 
a fleshy mole. This may be retained for many weeks or 
even months. 

Mummification takes place only when the foetus has 
died in the middle or later months of development. The 
soft structures become dried and shrunken and the skin 
assumes a yellowish-gray color. The placenta undergoes 
somewhat similar changes. 

A foetus papyraceus is a mummified twin foetus which 
after death in utero has become flattened by the pressure 
of its living companion. The head in such cases is fre- 
quently pressed into the shape of a meniscus lens. 

Maceration. — In maceration of the foetus the tissues 
become softened and sometimes swollen and the abdomen 
is distended. The epidermis is exfoliated and the serous 
cavities contain blood and serum. The odor is sickening, 
but not putrefactive. 



PATHOLOGY OF PREGNANCY. 219 

Putrefaction takes place only when the foetus is carried 
for a time in utero after the membranes have ruptured. 
The connective tissues become emphysematous, the ab- 
domen is distended and the body emits a putrefactive 
odor. The uterus sometimes is tympanitic and the mother 
suffers more or less from septic absorption. 

Treatment in Foetal Death. — The uterus should be 
emptied immediately the diagnosis of foetal death can be 
positively established. The presence of a dead foetus in 
utero is always injurious to the health and may become 
dangerous to the life of the mother. 

In the first three or four months of pregnancy the 
method to be pursued is the same as for the induction of 
abortion. In the later months labor is induced as in other 
cases of advanced pregnancy. The uterine cavity should 
be cleansed carefully after the labor. 

ABORTION. 

Definition. — As commonly used abortion applies to ex- 
pulsion of the ovum during the first three months of ges- 
tation, miscarriage to its expulsion during the next three 
months and premature labor to the birth of a viable 
foetus before term. Yet abortion and miscarriage are 
used interchangeably. 

Frequency. — It is estimated that not far from 20 per 
cent, of pregnancies end in abortion. This estimate is 
doubtless too small if abortions from all causes are in- 
cluded. Owing to the influence of the menstrual moli- 
men spontaneous abortions occur most frequently at the 
end of the menstrual month. In a large proportion of 
cases they take place at the second month, and are com- 
paratively infrequent after the third. 



220 ESSENTIALS OF OBSTETRICS. 

Causes. — In considering the etiology of abortion it 
must be borne in mind that the security of attachment 
between the ovum and the uterus differs greatly in dif- 
ferent cases. Influences quite sufficient to bring about 
the expulsion of the ovum in one pregnancy may have 
no such effect in another. 

The provoking causes of abortion may be grouped under 
two heads : (1) Those which act by first causing the death 
of the foetus. In the great majority of cases abortion re- 
sults from the death of the foetus. (2) Those which act 
independently of the death of the foetus. 

1. Death of the foetus may occur from : Malformation, 
disease, mechanical violence, maternal toxaemia or exces- 
sive anaemia, pathological conditions of the chorion, the 
amnion, the cord, the decidua. 

2. Causes acting independently of the death of the 
foetus are atrophy or hypertrophy of the endometrium, 
placenta praevia, oxytocics, reflex irritation of the uterus, 
e. g., from mammary or from rectal stimuli, epileptiform 
convulsions from uraemic or other causes, carbon dioxide 
poisoning, placental apoplexies, pelvic adhesions, uterine 
myomata, cancer of the uterus, misplacement of the uterus, 
over-distention from hydramnios or from multiple preg- 
nancy, direct interference, falls or blows, hyperaemia of 
the pelvic organs from circulatory obstruction in the lungs 
or liver, from valvular heart disease, from violent mus- 
cular exertion, or from sexual excesses, etc., resulting in 
hemorrhage into the placenta. 

Diagnosis. Symptoms. — The symptoms of beginning 
abortion are : Hemorrhage, pelvic tenesmus, rhythmical 
uterine pains. 

Physical Signs. — The physical signs are effacement of 



PATHOLOGY OF PREGNANCY.' 221 

the os internum, dilatation of the cervix and partial pro- 
trusion of the ovum from the uterine cavity. 

The physical signs establish the diagnosis of inevitable 
abortion. They imply a degree of separation of the ovum 
from the lower uterine segment too great to permit the 
farther continuance of the gestation. Severe rhythmical 
pains with hemorrhage almost surely forebode the expul- 
sion of the ovum. Not only should a thorough physical 
examination of the pelvic organs be made in every case of 
suspected abortion, but blood-clots and other material cast 
off from the genital passages should be inspected. Other- 
wise the ovum when expelled enveloped in a mass of co- 
agulated blood may escape observation. Clots are best 
examined by breaking them up under water. 

Abortion in the first weeks of gestation is not always 
easily distinguished from dysmenorrhea or simple uterine 
hemorrhage. Here the diagnosis will depend mainly on 
the evidence of pregnancy as shown by the shape, size 
and consistence of the uterus, and on the presence of the 
foetal structures in the genital discharges. Free hemor- 
rhage with expulsion of large blood-clots is significant of 
abortion. 

Ectopic gestation is often mistaken for simple abortion. 

Prognosis. — There is no mortality in properly conducted 
abortions, yet many deaths occur from mismanagement. 
The principal sources of danger are hemorrhage and septi- 
caemia. Hemorrhage contributes to the fatal issue, though 
it is rarely the immediate cause of death. The danger of 
sepsis is especially imminent in incomplete abortion. The 
presence of necrotic material in the uterus is a serious 
menace to life. It is a potent cause of pelvic infection 
in cases which escape a fatal termination. 



222 ESSENTIALS OF OBSTETRICS. 

Treatment, (a) Prophylaxis in Habitual Abortion. — 
The preventive treatment of abortion is addressed chiefly 
to the cause. 

Syphilis in one or both parents, retroversion of the 
uterus and endometritis are the most frequent causes of 
habitual abortion. Syphilis is treated as in other cases. 
It is not always possible to save the ovum by treatment 
begun after conception. 

Retroversion is corrected and its recurrence is pre- 
vented by the use of a suitable pessary till after the third 
month. 

Endometritis is best treated by curettage in the in- 
terval between pregnancies. 

It is important to guard against overexertion, mechan- 
ical violence and the causes of pelvic congestion, espe- 
cially at the menstrual dates. Rest in bed during the 
menstrual epochs and abstention from sexual intercourse 
should be enjoined till the critical period has passed. 

(b) Arrest of Threatened Abortion. — Enforce absolute 
rest in the recumbent position. The patient should not 
be permitted to rise for any purpose till all symptoms of 
abortion have subsided. Uterine rest is maintained by 
the use of opium, gr. ij, or its equivalent, p. r. n. A 
four-grain pill of extract of viburnum prunifolium is use- 
ful as an adjunct, even as a substitute for opium. 

Misplacements of the uterus must be corrected. Ex- 
clude vesicular degeneration of the chorion and death of 
the embryo or foetus, in either of which conditions the 
uterus should be evacuated. 

(c) Management of Actual Abortion. — The general ob- 
jects of treatment are the prevention of : (1) hemorrhage; 
(2) septicaemia. 



PATHOLOGY OF PREGNANCY. 223 

Measures of controlling hemorrhage are : (1) Rest ; (2) 
firm cervical and vaginal tamponade ; (3) evacuation of 
the uterus. 

Means for averting or controlling sepsis are : (1) The 
avoidance of preventable lacerations and abrasions ; (2) 
asepsis ; (3) timely evacuation of the uterus. 

1. Expectant Plan. — Indications : Ovum but little de- 
tached, hemorrhage slight, sepsis absent. 

Method. — Usually no interference is practised except 
such as is needed for cleanliness. An aseptic vaginal 
tampon may be used if required as a safeguard against 
hemorrhage. This plan failing after twenty-four hours 
empty the uterus with curette and forceps — sooner for 
cause. 

Method of Tamponade. — Place the patient in the Sims 
position and expose the cervix with a Sims speculum. 
The material for the tampon may be aseptic cot ton- wool, 
used wet enough to pack firmly, and in pledgets the size 
of a chicken's egg. Place a row of pledgets in the fornix, 
around the cervix, and build up from this until the vagina 
is full. Press the packing away from the urethra and 
base of the bladder to prevent vesical irritation. Hold it 
in place with a T-bandage. 

Sterilized gauze in strips two and one-half inches, wide 
and five yards long is a better material for the tampon 
than the cotton-wool. The simple aseptic packing must 
be renewed every twelve hours. A tampon impregnated 
with oxide of zinc may stand twenty-four hours. Mer- 
curials should not be used in the tampon. The vagina 
should be irrigated at each renewal of the dressing. 

2. Radical Plan. — Indications : Cervix dilated, the 
ovum detached or presenting or partially expelled, hem- 
orrhage excessive, sepsis present or imminent. 



224 ESSENTIALS OF OBSTETRICS. 

Manual Method. — The abdomen, thighs, and vulva 
are thoroughly cleansed with soap, hot water and a soft 
brush, and the vagina if believed to be infected is douched 
and is scrubbed gently with a soft cheese-cloth sponge 
held in the grasp of a dressing forceps, and finally irri- 
gated with the antiseptic solution for five minutes. The 
cervical canal is freed from mucus and disinfected. 

Usually no anaesthetic will be required. The uterus is 
crowded down and fixed with one hand over the abdomen, 
and the cavity is evacuated with one or two fingers of 
the other hand, aseptically. The manual method is 
awkward, and difficult except the ovum is nearly or quite 
detached and the cervix well open ; even then it is infe- 
rior to the instrumental. 

Instrumental Method. — Anaesthesia is necessary as a 
rule. The patient may be placed in the Sims or in the 
dorsal position, and the cervix exposed by means of a 
Sims speculum or other suitable retractor. The anti- 
septic preparation is carried out as already detailed. 
The anterior lip of the cervix is caught and held gently 
forward toward the pubic bones with a volsella. The 
uterine cavity, if septic, is douched with the antiseptic 
solution, otherwise with the salt solution (^ per cent.), 
or with plain sterilized water. The ovum is detached 
with the curette and removed with a pair of long, straight, 
uterine dressing-forceps having a joint about two and a 
half inches from the distal end. Every part of the cavity 
is curetted thoroughly but lightly with a sharp curette 
and again douched. Care will be required to remove all 
the decidua from the cornua. A special small curette 
will be found useful for this purpose. The uterus after 
complete evacuation may be swabbed with tincture of 



PATHOLOGY OF PREONANGY. 225 

iodine if hemorrhage is not controlled by the curette. 
Only normal salt solution or plain sterilized water should 
be used in the uterus in the absence of septic material. 
Strong antiseptics leave a superficial necrotic layer which 
furnishes a favorable nidus for the growth of septic or- 
ganisms. A relaxed uterus after abortion calls for ergot. 
If the secundines are necrotic the uterine cavity may be 
packed lightly with a strip of iodoform gauze an inch in 
width. The packing should be removed after twenty -four 
or thirty-six huars. 

The presence of a peri- or parametritis does not forbid 
interference. It makes it rather the more imperative. 
Sepsis in the uterine cavity tends to perpetuate the peri- 
uterine inflammation, maintaining the supply of septic ma- 
terial. 

Incomplete Abortion. — Continuous or irregular hem- 
orrhage, sepsis or failure of involution after abortion is 
probable evidence that portions of the ovum have been 
retained. In such cases the uterine cavity should be dis- 
infected, explored, and, if necessary, curetted. 

After-treatment of Abortion. — The patient remains in 
bed for a week or more. The external genitals must be 
kept scrupulously clean. If the uterine cavity has been 
completely and aseptically evacuated after abortion, sub- 
sequent interference within the passages will not be re- 
quired. The temperature and the character of the genital 
discharge are to be watched for several days. Before the 
case is finally dismissed the physician should assure him- 
self of the condition of the pelvic organs by careful bi- 
manual examination. 
15 



226 



ESSENTIALS OF OBSTETRICS. 
PREMATURE LABOR. 



The causes of premature labor are essentially those of 
abortion. Its course and management do not differ in 
any important particular from those of labor at term. 

ECTOPIC GESTATION. 

Definition. — Pregnancy outside the uterine cavity. 
Varieties, (a) Tubal Pregnancy. — In tubal pregnancy 
the impregnated ovum lodges and begins development in 

Fig. 53. 




Ectopic pregnancy ; rupture of fruit-sac into peritoneum. (After Schaeffer.) 

the Fallopian tube. Practically all extra-uterine preg- 
nancies are primarily tubal. 

(b) Abdominal Pregnancy. — Sooner or later, if the de- 
velopment of the ovum is not interrupted, the tube rup- 
tures, usually into the peritoneum, rarely into the broad 
ligament, because incapable of accommodating itself to 
the growth of the ovum. When after rupture of the tube 



PATHOLOGY OF PREGNANCY. 227 

and the partial expulsion of its contents the ovum survives 
and grows in the abdominal cavity, either within or without 
the peritoneum, the pregnancy is said to be abdominal. 
Primary abdominal pregnancy does not occur. 

(c) Ovarian Pregnancy. — The ovum is impregnated in 
the Graaffian follicle and developed in the ovary. Ova- 
rian pregnancy, however, is so extremely rare that it will 
be dismissed with mere mention. 

Frequency. — The frequency of extra-uterine pregnancy 
is variously estimated at from 1 in 313 to 1 in 1,200 
pregnancies. 

Etiology. — The etiology of ectopic pregnancy is still 
obscure. Among the causes which have been assigned 
are partial obstruction of the tube, sacculation of the tube 
and crippled peristalsis or denudation of ciliated epithe- 
lium from old catarrhal inflammation with consequent loss 
of propelling power. In the majority of cases according 
to Herzog, the cause is to be found in congenital anomo- 
lies. 

Clinical Course. — Two classes of cases may be distin- 
guished according to the location of the fruit-sac : A. 
Pregnancy in the free portion of the tube ; B. Pregnancy 
in the intramural portion, or interstitial pregnancy. 

A. Pregnancy in the free portion of the tube may have 
either of the following terminations : 

1. The ovum may rupture and be expelled through 
the fimbriated extremity of the tube into the peritoneal 
cavity — tubal abortion. 

2. The ovum may die without rupture or Avith partial 
rupture of the tube. In this event 

(a) It may form a mole or a hematosalpinx. 

(b) It may suppurate, forming a pyosalpinx. 



228 ESSENTIALS OF OBSTETRICS. 

(c) In early gestation it may be absorbed ; in more ad- 
vanced pregnancy it may become mummified or be con- 
verted into adipocere or a lithopsedion. 

3. The tube may rupture into the peritoneum (usually 
before the eighth or twelfth week) with either of the fol- 
lowing results : 

(a) Very rarely the gestation continues as an abdom- 
inal pregnancy. In these cases the placenta retains its 
tubal attachment, the foetus with its membranous en- 
velope being expelled into the peritoneum. 

(6) Hemorrhage occurs into the peritoneum, the mother 
dying from hemorrhage or peritonitis. 

(c) The hemorrhage may be spontaneously arrested. 
The ovum may then be absorbed, may suppurate, or may 
remain with little change. 

4. When the fruit sac is lodged in the inner two-thirds 
of the tube the tube may rupture into the broad ligament. 
Rupture between the folds of the broad ligament is not 
so common as formerly supposed. Intraligamentous rup- 
ture may terminate as follows : 

(a) The placenta not being wholly detached, the ovum 
may continue to grow — intraligamentous pregnancy. This 
form of ectopic gestation may go to term. This is one 
form of abdominal pregnancy. Spurious labor occurs at 
term and the child dies. 

(6) Death of the ovum and the formation of a hema- 
toma may result. 

(c) The ovum may die and suppurate. A suppurating 
ovum may be discharged piecemeal through the ab- 
dominal wall, the vagina, the bladder, the rectum ; may 
result in septicaemia and death. 

(d) The ovum may die, and, if the development has 



PATHOLOGY OF PREGNANCY. 229 

advanced to the later months, be carried indefinitely, with 
little or no alteration of structure, or be converted into a 
lithopsedion or a mass of adipocere. 

(e) Secondary rupture may take place into the peri- 
toneal cavity. 

4. Pregnancy in the outer third of the tube may become 
a tubo-ovarian or a tubo-abdominal pregnancy. 

B. Pregnancy in the intramural portion of the tube, tubo- 
uterine pregnancy, interstitial pregnancy. 

1 . May terminate by the death of the ovum. 

2. May terminate by expulsion of the ovum into the 
uterus. 

3. May rupture into the peritoneal cavity, with death 
of the mother by hemorrhage. Rupture generally occurs 
before the sixth month. 

4. May rupture into the broad ligament. 
Diagnostic Signs in the Early Months. 1. History. — 

Antecedent sterility, signs of pregnancy. Frequently a long 
period of sterility has immediately preceded the pregnancy. 

2. Uterus. — Displaced, according to the size and situa- 
tion of the fruit-sac ; enlarged, empty, cervix open. 

3. Tumor. — Beside or behind or in front of the uterus, 
fluid, tense, tender, pulsating, rapidly growing. 

Unfortunately, opportunity for physical examination is 
seldom afforded before rupture. 

Diagnostic Signs in the Later Months. — The foetal 
movements are usually more distinct than in the utero- 
gestation ; 

The foetus is more accessible to palpation ; 

The foetal heart-tones are more intense ; 

Ballottement is obtainable in the fourth and fifth 
months ; 



230 ESSENTIALS OF OBSTETRICS. 

Shrinkage of the tumor usually ensues upon the death 
of the foetus ; 

The uterus can be differentiated from the tumor ; 

Most reliable in the later months is evidence of preg- 
nancy with a uterus but little developed and distinguish- 
able from the tumor. 

Signs of Primary Rupture. — Pelvic and abdominal pains, 
usually violent ; 

Irregular genital hemorrhage ; 

Symptoms of acute internal hemorrhage, with more or 
less collapse ; 

The pain usually occurs in paroxysms. It is cramp- 
like in character and is referred to the seat of the fruit- 
sac. The final and more acute paroxysms are usually 
attended with collapse and with the signs of internal 
hemorrhage. Exceptionally the symptoms are not well 
marked. 

The genital hemorrhage is irregular in occurrence and in 
amount. It is observed especially at the times of the pain- 
ful paroxysms, and a more or less profuse discharge of 
blood commonly attends the rupture of the fruit-sac. 

Decidual Cast. — In ectopic pregnancy, as in normal 
gestation, a decidua is developed from the uterine mucosa. 
At the termination of the pregnancy the decidual mem- 
brane is expelled entire or piecemeal. 

This is distinguished by its histological characters from 
the products of intrauterine pregnancy and from the cast 
of endometritis. Under the microscope it differs from the 
former by the absence of evidence of implantation of chorial 
villi ; from the latter, according to certain authorities, by 
the presence of decidual cells, which are round or oval 
granular bodies, each containing a well-defined nucleus or 



PATHOLOGY OF PREGNANCY. 231 

several nuclei, and having a diameter five to fifteen times 
that of a red blood-corpuscle. 

The physical signs of pelvic hematocele or hematoma ; 

Evidence of moderate peritonitis within two or three 
days after rupture. 

In tubal rupture with much hemorrhage the clinical 
picture is unmistakable. It is not so plain when the 
blood-loss is small. Abortion and dysmenorrhoea some- 
times simulate very closely ruptured tubal pregnancy and 
these must be excluded. 

Intraperitoneal rupture is usually distinguished from 
extraperitoneal by more hemorrhage and by the physical 
signs of the free fluid in the pelvic peritoneum. The 
presence of free blood, and even of soft blood-clots in the 
peritoneal cavity, is difficult of recognition by the vaginal 
touch. When the blood effusion is encysted the condition 
cannot be distinguished from hematoma in the broad liga- 
ment. In intraperitoneal rupture a large, firm clot may 
be present in the tube, simulating a clot in the broad 
ligament. 

Extraperitoneal rupture is characterized by the presence 
of a circumscribed and more or less firm tumor (blood- 
clot) in one broad ligament as revealed by the vaginal 
touch. The blood collection may dissect up the peri- 
toneum and burrow behind the uterus. Examination by 
the rectum and, if necessary, under anesthesia facilitates 
the diagnosis. A sacculated tube firmly adherent to the 
broad ligament, or encysted intraperitoneal blood may 
counterfeit intraligamentary rupture and maybe mistaken 
for it even at operation. 

Before opening the abdomen, if the diagnosis cannot be 
established, otherwise the uterine cavity may be explored 



232 ESSENTIALS OF OBSTETRICS. 

with the finger. It should not be forgotten that intra- 
and extrauterine pregnancy may coexist. 

Differential Diagnosis. — Ovarian cyst, ovarian abscess, 
dermoid cyst, intraligamentous cyst, simple fluid accumu- 
lations in the tube — hydrosalpinx, pyosalpinx and hemato- 
salpinx — and a retroverted and gravid uterus must be ex- 
cluded. 

Differentiation from pregnancy in the rudimentary 
horn of a uterus unicornis is difficult or impossible ; but 
it is practically unnecessary, since the treatment is essen- 
tially the same in either condition. Left to themselves 
80 per cent, of the latter class of cases terminate in rup- 
ture. As a rule no symptoms occur to arrest the atten- 
tion of patient or physician before the uterus ruptures. 

Treatment Before Primary Rupture. — 1. Celiotomy and 
removal of the pregnant tube. In the abdominal operation 
the incision is made in the median line above the pubes 
large enough to admit the hand. The ovarian artery of 
the affected side is clamped immediately with catch-forceps 
close to the uterus, and again in the ovario-pelvic liga- 
ment just without the tube. Adhesions are broken up, 
the fruit-sac with the ovary and tube is lifted up and, by 
a crescentic incision, enough of the upper border of the 
broad ligament is cut away to carry with it the gestation- 
sac with the tube and ovary. The free ends of the di- 
vided artery and vein are now sought out and tied with 
fine catgut between the folds of the peritoneum. The 
clamps are removed and the edges of the peritoneum 
whipped together with a running suture of fine catgut. 

2. Vaginal Incision. — Removal of the pregnant tube 
by the vaginal route is sometimes practicable. Either 
the anterior or the posterior incision may be adopted. 



PATHOLOGY OF PREGNANCY. 233 

The technique is simpler in the latter. A half-inch inci- 
sion is made transversely near the junction of the vagina 
with the uterus, usually 4 cm., 1J inch above the lower 
border of the cervix. The opening is then enlarged with 
the fingers. Tube and ovary are liberated, brought down 
into the vagina and tied off. The incision is closed with 
sutures. Operation by vaginal incision, however, is 
rarely to be recommended. The work can be done more 
safely and thoroughly by the abdomen. 

3. Foeticide by electricity or by the injection of drugs 
into the fruit-sac is no longer practised. 

Treatment after Rupture into the Peritoneum. Imme- 
diate Cceliotomy. — Method substantially as before rupture. 
The blood is removed from the peritoneal cavity and the 
peritoneum either sponged dry or irrigated with sterile 
normal salt solution — teaspoonful of salt to a quart of 
water. A few quarts of the saline solution may be left in 
the peritoneum to help refill the vessels. Vaginal drain- 
age for one or two days is sometimes advisable. 

In extreme anaemia and collapse a quarter grain of 
morphine may be given hypodermically a half hour before 
operating. A pint of normal salt solution should be in- 
jected behind each breast immediately before or during 
the operation if the woman has lost much blood. 

If cceliotomy is refused the case must be trusted to rest 
with the use of sand-bags on the abdomen over the 
fruit-sac. 

Treatment after Rupture into the Broad Ligament. 
First Three Months. — Limited effusions of blood do not 
necessarily require surgical intervention. Should the 
cyst-contents become septic the sac should be opened, 
either by the abdomen or by the vagina. In the abclom- 



234 ESSENTIALS OF OBSTETRICS 

inal operation the sac is evacuated, as much of it is re- 
moved as possible, the bleeding stopped, the remnant of 
the sac closed and drained through the vagina. A large 
hsematonia is generally best treated in like manner. 

When the suppurating sac or small hematoma is accessi- 
ble by the vagina it is best opened and drained from below. 

If the ovum survives rupture of the tube into the 
broad ligament, it should be treated as a malignant 
growth by coeliotomy and extirpation of the fruit-sac. 
The life of the child in extrauterine pregnancy is of too 
little value to weigh against the interests of the mother. 

After the Third Month. — The foetus may still be extra- 
peritoneal. Coeliotomy and removal, if possible, of the 
entire ovum are indicated once the diagnosis is estab- 
lished. When the foetus has been dead for two or three 
months the placental vessels w T ill be found obliterated and 
the complete extirpation of the sac is generally possible. 
Tying the ovarian artery on either side of the fruit-sac 
usually controls the hemorrhage. Moderate bleeding 
after removal of the placenta may be taken care of by 
packing the bleeding cavity firmly with gauze, the lower 
end of the abdominal incision being left open for one or 
two days. 

If the foetus is living it is not advisable usually to 
attempt the removal of the placenta. The sac may be 
stitched to the abdominal wall and the placenta left to 
separate, which usually occurs within a week or ten days. 
The recovery, however, is tedious, and attended with no 
little risk of septicaemia. When possible all or the larger 
portion of it should be removed after tying the arteries 
on both sides and ligating the base in sections. 

Secondary Rupture.- — After secondary rupture into the 



PATHOLOGY OF PREGNANCY. 235 

peritoneum the treatment is the same as in primary intra- 
peritoneal rupture. 

Treatment of Interstitial Pregnancy. — When the diag- 
nosis is possible the pregnancy may sometimes be termi- 
nated safely by emptying the fruit-sac through the uterine 
cavity. On intraperitoneal rupture cceliotomy is indi- 
cated as in pregnancy in the free portion of the tube. 
Supravaginal amputation of the uterus may also be 
required. 

PERNICIOUS VOMITING OF PREGNANCY. 

Etiology. — The hyperemesis of pregnancy is to a greater 
or less extent a neurosis. In many instances it is a reflex 
disorder, dependent upon some anatomical lesion of the 
pelvic organs, such as uterine displacement, detention of 
the uterus in the pelvis by adhesions or other cause, de- 
cidual endometritis, induration of the cervix, erosion or 
inflammation of the cervix, perimetritis, yet it may occur 
independently of any discoverable pelvic disease. Lesions 
of other than the pelvic organs, and especially of the 
kidneys, may be complicating causes. 

Prognosis. — In the majority of cases the nausea of preg- 
nancy subsides by the third or fourth month, when the 
uterus rises out of the pelvis. In persistent uncontrol- 
lable vomiting the prognosis is grave. 

Treatment, (a) Dietetic Measures. — Useful dietetic 
measures are : Breakfast in bed, followed by sleep ; an 
ounce of sherry wine or a small cup of strong coffee be- 
fore rising, a glass of cold Vichy or carbonated water 
several times daily ; to this sodium bromide is a useful 
addition, one drachm to the siphon. Panopeptone or other 
predigested foods are often well borne. Other dietetic 



236 ESSENTIALS OF OBSTETRICS. 

measures, such as are practised in ordinary vomiting, may 
be of service. The longings of the patient frequently af- 
ford a reliable guide to the feeding. 

Fasting for two or three days, sipping hot water at fre- 
quent intervals is useful. 

Rectal alimentation must be relied on when stomach 
feeding is impossible. Beef blood, uncooked beef-juice, 
peptonized meat solutions, or predigested milk, ,§iv, q. 6 
h., is a suitable food for the purpose. Five minims of 
deodorized tincture of opium may sometimes be added to 
the nutrient enemas with advantage. A large soft-rubber 
catheter or small rectal tube of similar material, with a 
funnel attached to the distal end, serves best for admin- 
istering the food injections. The tube should be well 
lubricated and passed high up in the rectum with care to 
avoid irritatiug the bowel. The rectum should be washed 
out twice daily during rectal feeding. 

(b) General Therapy. — Complete rest in bed for sev- 
eral days is an important aid in controlling the vomiting. 
Position with the shoulders low and hips elevated helps. 

Useful drug measures are : Cocaine, gr. ^ to \ repeated 
three or four times daily, or hourly until three or four 
doses are given ; cocaine spray to the pharynx or to the 
nares, 1 per cent, solution ; chloral, gr. xx to xxx, in 
solution by the rectum, two or three times daily, best given 
in milk ; the bromide of sodium in similar doses. Strych- 
nine, gr. -jL to g^Q, or tincture of nux vomica, Tu\ v in 
water before meals, is indicated in chronic gastric catarrh. 
Calomel, in small repeated doses, gr. J-^-, q. J h., to 5 
or 10 doses often does valuable service. Oxalate of 
cerium, gr. x, q. 2 h., when it can be retained, or subnitrate 
of bismuth in similar doses may be tried. 



PATHOLOGY OF PREGNANCY. 237 

Ether spray to the epigastrium at the onset of each 
paroxysm is sometimes effective. An ice bag over the 
cervical vertebrae, or blister over the fourth or fifth dorsal 
vertebra? may help. Oxygen by inhalation has been used 
with success. A weak faradic current through the 
stomach sometimes relieves. Galvanism is thought to be 
of value. The anode is placed over the clavicle between 
the two branches of the sterno-cleido-mastoid muscle, the 
cathode over the umbilicus. The current strength should 
be 10 to 15 milliamperes continued from fifteen to thirty 
minutes. Other remedies such as are useful in vomiting 
from other causes may be found of service. Combat 
toxaemia by stimulating the emunctories. 

(c) Local Measures. — Cervical erosions should be 
touched with a twenty-grain solution of nitrate of silver 
every second day. Utero-displacements must be cor- 
rected. A vaginal gauze pack, renewed every two 
days, is often helpful. Sexual intercourse should be 
forbidden. 

Galvanism of the uterus is sometimes useful. The 
anode is applied to the cervix, the cathode over the lower 
dorsal vertebrae. A current of 3 to 5 milliamperes may 
be continued for five minutes. The sitting is repeated 
morning and evening. 

A 10 per cent, cocaine solution freely applied over the 
portio vaginalis and within the cervix may relieve. 

Copeman's method of dilatation of the cervix below 
the os internum, either alone or in combination with the 
foregoing cocaine method, is one of the most reliable 
measures for relieving the reflex disturbance. This treat- 
ment may result in abortion, and should be adopted only 
as a dernier ressort. 



238 ESSENTIALS OF OBSTETRICS. 

Induction of abortion is indicated when other means 
fail. It should not be too long withheld. It is justified 
only when the mother's life would be endangered seriously 
by longer continuance of the pregnancy, and then only 
with the concurrence of counsel. 

Methods of Inducing Abortion. — Partial separation of 
the ovum with a sound and packing the cervix with iodo- 
form gauze which is renewed every twelve to twenty-four 
hours are satisfactory methods. Either may be relied on 
or both may be combined. After the os internum is 
effaced the dilatation may be completed manually or in- 
strumentally if the indication is urgent. 

In experienced hands the rapid method of evacuating 
the uterus with the curette and a Keith forceps will 
be found best. The cervix is first dilated with a steel 
branched dilator till the curette passes readily. The 
major portion of the ovum is brought away with the for- 
ceps and the rest, including the decidua, with the curette. 
The uterus can easily be emptied in ten or fifteen minutes. 
The patient should be under an anaesthetic. 

PTYALISM. 

Ptyalism, like the nausea of pregnancy, with which it 
is usually associated, is believed to be a reflex disorder. 
By certain authorities it is ascribed to a toxin. Trouble- 
some salivation is comparatively rare. 

Treatment. — Treatment is unsatisfactory. The follow- 
ing measures are sometimes of service : A saturated solu- 
tion of potassium chlorate used several times hourly as a 
mouth wash ; sulphate of atropine, gr. yi-^ once to three 
times daily per os ; the bromides, gr. xxx to cxx daily ; 
tincture of the chloride of iron, Tltv t. i. d. Salivation 



PATHOLOGY OF PREGNANCY. 239 

is usually most relieved by treatment which subdues the 
nausea. 

ANEMIA. 

Treatment. — Blaud's pill, one or two t. i. d.; arsenate 
of iron gr. ^V to y^- t. i. d.; albuminate of iron in full 
doses ; a solution of citrate of iron, gr. j hypodermically, 
are useful hsernatinics. A generous diet is essential. 

VARICES OF THE LOWER EXTREMITIES. 

They are frequently present in the later months of 
pregnancy. 

Treatment. — The treatment consists in support with 
bandages or elastic stockings. Much standing is obvi- 
ously injurious. 

PRURITUS VULVAE. 

Treatment. — Place the patient in the Sims position, 
retract the posterior vaginal wall with a Sims speculum 
and dust the vaginal and vulvar surfaces with subnitrate 
of bismuth. Repeat daily or every two days. Fomen- 
tations to the itching parts with plain hot water or with 
a 2J per cent, carbolic solution give temporary relief. 
Applications of cocaine hydrochlorate are useful. If the 
pruritus is of diabetic origin treatment must be addressed 
to the cause. 



CHAPTER VI. 

PATHOLOGY OF LABOR. 

ANOMALIES OF THE MECHANISM. 

A. ANOMALIES OF THE EXPELLING POWERS. 
1. Excess : Precipitate Labor. 

Cause. — The cause of precipitate labor may be excessive 
activity of the expelling forces, or deficient resistance as 
in large pelvis or small head. 

Dangers. — The dangers are for the most part insignifi- 
cant. The principal risks to the mother are of lacerations, 
especially in primiparse, shock and post-partum hemor- 
rhage ; to the child, asphyxia from the nearly continuous 
interruption of the utero-placental circulation, and the 
possible accidents of sudden and unexpected birth, such 
as falling on the floor, precipitation into a water closet, 
rupture of the cord. 

Treatment consists in moderating the expelling forces 
by regulating the abdominal pressure, and, if required, by 
chloroform. The patient should be kept in bed from the 
onset of the pains. 

2. Deficiency : Prolonged Labor. 
I. Prolonged First Stage. Tardy Dilatation. 

(a) Simple Inertia Uteri: Feeble Pains. 
Causes are emotional disturbance, full bladder or rectum, 
impaired muscular tone. Often the cause is obscure. 



PATHOLOGY OF LABOR. 241 

Treatment. — In the absence of danger to mother or 
child, the treatment should be expectant. Simple inertia 
uteri calls for no intervention so long as the membranes 
are unbroken and the patient gets sleep and nourishment 
enough. The bladder and rectum should be evacuated 
frequently, and other causes of inertia removed if pos- 
sible. 

Measures for accelerating the first stage, when interven- 
tion is required in the interests of one or both patients, 
are : Keeping the patient up and moving about, a hot sitz 
bath, a rectal injection of glycerin, §ss, the alternate use 
of hot and cold compresses over the abdomen, strychnine, 
gr. -gL- every four hours hypodermically, to arouse the 
nervous system, or quinine gr. v to x, moderate stimula- 
tion with wine, whiskey or other alcoholic stimulants, the 
faradic current from the upper sacral region to the pos- 
terior vaginal fornix, peeling up the membranes from the 
lower uterine segment, the passage of an aseptic bougie 
between the membranes and the uterine walls, artificial 
dilatation with the hand or with water-bags. Interfer- 
ence within the passages, however, should generally be 
withheld if possible. 

(b) Cramp-like Pains. 

The uterine contractions are painful but are inefficient, 
being more tonic than clonic. There is consequent fail- 
ure of the normal changes in the lower segment and cer- 
vix which favor dilatation, even in the presence of appar- 
ently active pains. 

Causes are neurotic influences, excessive uterine disten- 
tion, as in hydramnios or twins, dry labor, and the conse- 
quent unequable pressure upon the cervix, malpresentation, 
16 



242 ESSENTIALS OF OBSTETRICS. 

too firm adhesion of membranes at the lower uterine seg- 
ment. 

Symptoms. — The woman suffers excessive pain, yet the 
labor makes little or no progress. Mechanical obstruction 
must be excluded. The cervix is rigid, and if the mem- 
branes have ruptured the caput succedaneum is excessively- 
developed. 

Dangers. — Dangers are of exhaustion in proportion to 
the severity of the pain and the loss of sleep and nourish- 
ment ; in dry labor, pressure-effects in both mother and 
child and septic infection. Atony of the uterus is likely 
to result. Exhaustion predisposes to a slow second stage. 

Treatment. — Chloral, 5j in four doses of gr. xv each, at 
intervals of fifteen minutes, frequently does good service. 
Still more effective is opium, gr. j, once or twice repeated, 
if necessary, at intervals of an hour. These narcotics 
may do either of two things : they may regulate the ac- 
tion of the expelling powers by abolishing in part the in- 
hibitory influence of pain, or by inducing sleep they may 
invigorate the natural forces. 

The application of a ten per cent, solution of cocaine to 
the cervix is said to be followed by prompt dilatation. 

Chloroform is very seldom permissible in this stage ex- 
cept as an aid to surgical intervention. Rupture of the 
membranes is indicated in marked hydramnios, peeling 
them up in undue adhesion. 

In dry labor gradual manual dilatation should be prac- 
ticed under anaesthesia. When time permits Barnes' bags 
may be used, but when efficiency and rapidity are de- 
manded the hand is better. Gentle traction with forceps 
may be tried after dilatation is nearly complete. 

Recourse may be had to multiple incisions of the cervix 



PATHOLOGY OF LABOR. 243 

or to Diihrssen's incisions when immediate delivery is re- 
quired. In the former method numerous shallow in- 
cisions are made in the lower border of the cervix with 
the scissors. The procedure is at once safe, simple and 
efficient. For the technique of Diihrssen's incisions the 
reader is referred to the chapter on obstetric surgery. 
With a normal head the space gained is sufficient for im- 
mediate delivery. Diihrssen's incisions are justifiable 
only as a last resort. 

II. Prolonged Second Stage. 

Causes. — The causes are most of those which operate 
in slow first stage. In addition may be mentioned ex- 
haustion, pendulous abdomen, excessive uterine retraction 
— retraction ring half way or more from the pubes to the 
navel — faulty action of the abdominal muscles. 

Symptoms. — The evidence of inefficient pains is obvious. 
In neglected cases the temperature and pulse begin to 
rise and the vagina becomes hot and dry. Obstructed 
labor must be excluded. 

Dangers. — Dangers to the mother are exhaustion and 
after-rupture of the membranes, pressure-effects, sepsis. 
Vesico-vaginal or recto-vaginal fistula? may ensue from 
long-continued pressure of the head in the lower part of 
the birth-canal ; in neglected cases extensive sloughing of 
the vaginal walls may result. 

To the child the dangers are chiefly pressure-effects. 
The foetal mortality is large from intracranial hemorrhage 
due to asphyxia or occurring as the direct result of trau- 
matism in instrumental delivery. Children who survive 
such injuries are not infrequently crippled in mind or 
body or both. 



244 ESSENTIALS OF OBSTETRICS. 

Treatment. — Obstructive causes are excluded by pass- 
ing the hand into the uterus if necessary. The bladder 
and rectum should be evacuated. Uterine obliquity may be 
corrected by manual support, by posture or by the binder. 
Summon the help of the abdominal muscles. Give qui- 
nine, gr. x, strychnine, gr. -^ hypodermically, or alcoholic 
stimulants. Apply hot fomentations to the hypogastric 
or the sacral region. Put the patient in the semi-recum- 
bent posture or squatting posture during the pains, 
or let her sit on the edge of the bed. Ahlfeld ? s birth- 
stool may be tried. This consists of two stools so placed 
as to leave a triangular space between them opening to 
the front. The woman sits over the open space until the 
head is about to be born. 

Use expressio foetus, applying the pressure at the upper 
foetal pole or to the head only when the latter pole pre- 
sents. Push aside intestinal loops and press downward 
in the axis of the inlet with one or both hands laid flat on 
the abdomen. The lithotomy position may help. 

Ergot in full doses is dangerous to the child and even 
to the mother. In large doses it tends to cause a persist- 
ent uterine contraction. In doses of ten minims of the 
fluid extract, repeated hourly, it merely increases the 
force and frequency of the natural labor pains. Its use is 
seldom permissible, never except in the absence of obstruc- 
tion and in minute doses such as to produce normal uterine 
contractions. 

Forceps is indicated when the natural forces are clearly 
incompetent or longer delay would jeopardize the life of 
mother or child. As a rule intervention is called for when 
the head has been arrested a half-hour, after two hours 
in the second stage, especially if the head is low down 



PATHOLOGY OF LABOR. 245 

and there is do recession between the pains. Failure of 
recession between the pains is evidence that the normal 
tonicity of the soft parts has been destroyed by prolonged 
pressure of the foetal mass. 

B. ANOMALIES OF THE PASSAGES. 

I. Anomalies of the Hard Parts : Deformed Pelvis. 

Frequency. — Contraction of some degree is present in 
from 10 to 15 per cent, of all parturients. Fortunately 
the higher grades of deformity are rare. Moderate con- 
traction is by no means so. Among women born in this 
country contraction of the pelvis is very seldom met with. 
Moderate non-rachitic flattening, and general contraction, 
kyphotic and scoliotic deformity are most frequent. 

Gravity. — The maternal and especially the foetal mor- 
tality are increased in proportion to the extent of deform- 
ity and the difficulty of delivery. 

The chief dangers are those of prolonged labor intensi- 
fied, to which are added those incident to operative inter- 
vention, malpresentation and malposition which occur 
more frequently than in normal pelves, and to prolapsus 
funis, rupture of the uterus and post-partum hemorrhage. 

The minor grades of deformity are dangerous for the 
most part to the child only. With early recognition and 
timely interference they usually present little difficulty. 

General Character of the Anomaly. — Exceptionally the 
abnormity consists in faulty inclination only. In the 
majority of contracted pelves the narrowing is at the brim 
and is most frequently an antero-posterior flattening. 
Obstruction may arise from old fractures, exostoses or 
other bony tumors. 



24(3 ESSENTIALS OF OBSTETRICS. 

Description of Forms. 

Simple Flat Pelvis. — This is the commonest variety of 
pelvic contraction. It consists simply of antero-posterior 
flattening. The intercristal and the interspinal diameters 
have the same value as in the normal pelvis or may be 
slightly increased. Their relation is the same as in the 
normal pelvis or nearly so. The circumference may or 
may not be diminished. The true conjugate seldom falls 
below three inches. The other internal diameters are nor- 
mal or nearly so. 

In this form of pelvic anomaly the woman is usually of 
full stature and her general appearance presents no evi- 
dence of deformity. 

Influence of Flat Pelvis on the Mechanism of Labor. — 
The head passes the brim with its long (occipito-frontal) 
diameter in the transverse of the pelvis and with the sagit- 
tal suture level or nearly so. Below the brim the head- 
movements are the same as in the normal pelvis. 

Flattened and Generally Contracted Pelvis. — This 
pelvis is contracted in all its diameters, but especially in 
the conjugate at the brim. Its cause is arrest of develop- 
ment affecting the innominate bones and the lateral masses 
of the sacrum. The promontory of the sacrum is higher, 
and the diagonal conjugate therefore longer, than normal 
notwithstanding the shortening of the true conjugate. 

Justo-minor Pelvis : Pelvis .ffiquabiliter Justo- 
minor. — This, as its name implies, is a generally con- 
tracted pelvis. Its diameters are not in all cases uni- 
formly contracted. In occasional instances the narrowing 
is confined chiefly to the outlet. The justo-minor pelvis 
is most frequent in women of small stature. Yet its size 
bears no relation necessarily to the size of the woman's 



PATHOLOGY OF LABOR. 



247 



body. This is a common form of contraction. It is due 
to arrest of development. 

Funnel-shaped Pelvis or Male Pelvis. — The pelvis is 
narrowed at the outlet ; the tubera ischiorum are approxi- 
mated ; the antero-posterior diameter at the outlet may be 
shortened. The subpubic angle is narrow. The sacrum 
is long and but little curved. The deformity is exceed- 
ingly rare. 

Kyphotic Pelvis. — The upper end of the sacrum is 
tilted backward. The pelvic inclination is diminished. 



Fig. 54. 




Naegele pelvis. 



The transverse diameter is increased in the false pelvis, 
somewhat diminished at the inlet of the true pelvis, and 
the conjugate is lengthened. The pelvis is funnel-shaped ; 
the ischial spines are strongly approximated. The sacrum 



248 ESSENTIALS OF OBSTETRICS. 

is narrowed, its longitudinal curvature diminished, its 
transverse curvature is increased, its lower end is dis- 
placed forward. The pubic arch is narrow, the symphysis 
is prominent. The cause of the deformity is kyphosis in 
the lumbo-sacral region. 

Naegele Oblique Pelvis : Ankylosed Obliquely Con- 
tracted. Pelvis. — There is complete or partial absence of 
one lateral mass of the sacrum, generally ankylosis of the 

Fin. 55. 




Section of spondylolisthetic pelvis. 

corresponding sacro-iliac joint and narrowness of the cor- 
responding half of the pelvis; the opposite side is in- 
creased in size. The shape of the brim is an oblique 
oval ; the symphysis is not opposite the promontory. The 
walls of the pelvic cavity converge below, the sacrum is 



PATHOLOGY OF LABOR. 249 

assymmetrical and the pubic arch narrower. This variety 
of deformity is very rare. (Fig. 54.) 

Ordinary Oblique-ovate Pelvis. — The shape is similar 
to that of the Naegele pelvis, but the deformity is due to 
coxitis; the contraction is on the side opposite the crippled 
member. 

Roberts Pelvis. — In the Roberts pelvis there is com- 
plete or partial absence of both lateral masses of the 

Fig. 56. 




Osteomalacic pelvis. 

sacrum. The conjugate is somewhat diminished. The sub- 
pubic angle is narrow. The deformity is exceedingly rare. 
Spondylolisthetic Pelvis. — The anomaly consists in a 
gliding forward of the last lumbar on the first sacral ver- 
tebra. The inferior surface of the former ultimately rests 
upon the anterior surface of the latter and becomes firmly 
united to it. Shortening of the antero-posterior diameter 
at the brim is extreme. Spondylolisthesis is very rarely 
met with. (Fig. 55.) 



250 ESSENTIALS OF OBSTETRICS. 

Osteomalacic Pelvis. — In osteomalacia the deformity 
arises from softening of the bones and consequent yielding 
in the direction of the existing pressures. The osteomal- 
acic pelvis is, accordingly, sometimes termed the com- 
pressed pelvis. The pubic portion of the pelvis is beak- 
shaped. The sacrum is convex from above downward and 
from side to side. The bisischial diameter is increased. 
(Fig. 56.) 

This is one of the rarest forms of contraction. 

Narrowing of the Pelvis from Bony Tumors. — Ob- 
struction of this form comprises simple exostoses, callus 
and displacement of bones due to fracture. 

Diagnosis of Pelvic Deformity. 

Clinical Data. — Evidence of rachitis in infancy, such as 
history of tardy dentition and of sweats, pigeon breast, 
curvature of the tibia, of the spine, or other asymmetry of 
the body, large joints, very low stature are significant of 
probable deformity. Disability of one lower extremity 
dating from infancy is almost surely attended with pelvic 
contraction. A pendulous abdomen, presenting pole per- 
sistently above the excavation during labor, deformities in 
near relatives or a history of difficult labors should excite 
suspicion. 

Pelvimetry. — The only means of exact diagnosis is the 
measurement of the pelvic diameters. Frequently the 
pelvis will be found contracted with no other evidence 
of abnormality than that afforded by pelvimetry. (See 
page 103 et seq.) 

The pelvis should be carefully examined by palpation 
with reference to its shape and symmetry. 

Most essential is the measurement of the external con- 



PATHOLOGY OF LABOR. 251 

jug-ate, the interspinal and the intercristal diameters exter- 
nally, and of the diagonal conjugate and the diameters of 
the outlet internally. The transverse and the oblique di- 
ameters at the brim internally are estimated with the hand 
in the passages. The shape and size of the sacrum, the 
presence or absence of bony tnmors and the general confor- 
mation of the pelvis are determined by external and inter- 
nal palpation. The pelvic inclination should also be esti- 
mated. 

In most cases the value of the external conjugate de- 
cides the question whether or not the pelvis is ample, since 
in nearly all forms of narrow pelvis the conjugate is di- 
minished. As a rule, with an external conjugate below 
17.5 cm., 7 inches, the internal conjugate is small; ex- 
ternal conjugate above 7 inches the internal conjugate is 
ample. Yet exceptionally the internal diameters of the 
brim may be normal when the diameter of Baudelocque is 
barely more than 16 cm., 6 \ inches, and on the other 
hand actual contraction may exist when the external con- 
jugate measures 20 cm., 8 inches. 

A pelvis with an external conjugate below 6 J inches is 
surely contracted ; a pelvis with an external conjugate 
above 8 inches is almost surely ample ; between these 
limits the question is left in doubt pending the internal 
examination. 

Internally, a diagonal conjugate of 11 cm. in flat or of 
11.5 cm. in generally contracted pelves should be classed 
as abnormally short. 

It must not be forgotten that the size of the foetal head 
is no less important a factor in the difficulty of delivery 
than is the capacity of the pelvis. The size of the head 
must, therefore, also be taken into account. The head 



252 ESSENTIALS OF OBSTETRICS. 

measurements cannot be so accurately determined as those 
of the pelvis. An approximate estimate is possible by 
measuring the accessible diameters of the head through 
the abdominal walls with a pelvimeter. It is also useful 
to try how far the head can be made to enter the brim by 
crowding it down with one hand over the lower part of 
the abdomen, while the fingers of the other hand passed 
internally estimate the depth of descent. When neces- 
sary for determining the size of the head during labor 
the half-hand should be introduced into the uterus. 

In slight disproportion it is often impossible to deter- 
mine definitely the prognosis for labor till the labor is well 
established. 

Management of Labor in Flat Pelvis. 

Conjugate 9 cm., 3 J inches* or more. — 1. The spontane- 
ous delivery of a living child is generally possible. The 
membranes should be preserved by colpeurynter if re- 
quired. Malpositions must be corrected. The bladder 
and the rectum should be emptied. 

When nature fails delivery may be effected by : 

2. Forceps, provided the head is engaged and the child 
liviug and viable. The forceps operation is here much 
more dangerous to mother and child than in the normal 
pelvis. 

3. Podalic version, when the head is not engaged, the 
child is alive and viable and other conditions are favorable. 

4. Craniotomy, as a rule, if the child is dead ; version 
or forceps may be chosen in easy extractions. 

5. Premature labor. The induction of premature labor 
at the thirty-sixth or thirty-eighth week may be consid- 
ered if the conditions are discovered in time. 



PATHOLOGY OF LABOR. 253 

Conjugate, 7 to 9 cm., 2f to 3J inches. — When the foetus 
is alive and viable Cesarean section or symphysiotomy 
is indicated. Symphysiotomy is best restricted to con- 
jugates between 7.5 cm., 3 inches, and 9 cm., 3 J inches ; 
when dead or non-viable podalic version or craniotomy is 
to be chosen. 

Artificial premature labor at or soon after the end of the 
eighth calendar month may be considered when the con- 
traction is recognized in time but the foetal mortality is 
high — about 33 per cent. 

Conjugate, 7 cm., 2f inches or Less, Absolute Contrac- 
tion. — At term the Csesarean section or the Porro opera- 
tion is indicated. When the deformity is known in time 
the induction of abortion should be considered. 

The choice of procedure, however, in narrow pelvis, 
must be determined by the relative, not alone by the actual 
size of the pelvis ; the degree of disproportion between the 
head and the pelvis must decide. The size of the head 
may be estimated by the methods just detailed. 

Management of Labor in Other Pelvic Deformities. 
\ The method of delivery must depend upon the kind and 
degree of obstruction. At term version or forceps is com- 
petent in a small percentage of cases. The possibility of 
a living birth by induced labor should be considered when 
the condition is discovered in time. 

Symphysiotomy is applicable when the conjugate is 
above three inches and there is but little contraction in 
other diameters. Craniotomy best serves the interests of 
the mother if the foetus is dead or non-viable. In the 
higher grades or disproportion, the Csesarean or the Porro 
operation is positively indicated and Csesarean section may 



254 ESSENTIALS OF OBSTETRICS. 

be preferred to symphysiotomy except in the least degree 
of disproportion or when the condition of the mother is 
bad for abdominal section. 

In excessive pelvic inclination the woman should be 
placed on the side to favor engagement of the head. 

When the pelvic inclination is diminished the liability 
to injuries of the pelvic floor is greater than in normal 
conditions. 

II. Anomalies of the Soft Parts. 

Vulvar Atresia. — Atresia may result from inflamma- 
tory adhesions of the labia rnajora, oedema vulvas, throm- 
bus, carcinoma, simple rigidity of the pelvic floor or rig- 
idity of the hymen. 

Treatment.— A large thrombus may require incision, 
evacuation of the blood-clots and packing the cavity. 
Nature or forceps is usually competent. A rigid hymen 
may call for single or multiple incisions. Other forms of 
rigidity, as a rule, may be trusted to forceps with, per- 
haps, episiotomy. 

Vaginal Atresia. — Two varieties are recognized, con- 
genital and acquired. The narrowing may be annular or 
may involve the whole length of the canal. In the an- 
nular variety multiple incisions and forceps will generally 
be required ; in complete atresia the Cesarean or Porro 
operation is the only resource. 

Cystocele. — The treatment consists in replacing the 
prolapsed bladder-wall after catheterizing. Evacuation 
by the catheter being impossible, the bladder may be as- 
pirated through the vaginal or the abdominal wall. 

Rectocele is replaceable with the aid of the Sims or 
the genupectoral position. It is rare that delivery is 
complicated with prolapse of the vaginal Avails. 



PATHOLOGY OF LABOR. 255 

Rigidity of the Cervix may arise from atrophic 
changes in aged primiparse, from hypertrophy of the 
portio vaginalis or from cicatrices. The dilatation is to be 
left to nature except in the presence of danger to mother 
or child. Artificial measures, if required, are Barnes 7 
hags, manual dilatation, multiple shallow incisions about 
the free border of the cervix, rarely deep cervical incis- 
ions. Good results have been claimed for a 10 per cent, 
solution of cocaine applied to the os uteri. 

Cancer of the Cervix. — The induction of premature 
labor, cervical incisions through the healthy tissue with 
a thermocautery knife and extraction with forceps are 
sometimes possible. The passages should be irrigated 
repeatedly with an antiseptic solution during and after 
labor. Mercurials, however, must not be used. 

Delivery with the aid of cervical incisions is advis- 
able only when hysterectomy is impracticable. Generally 
Cesarean section is required. It is best done before 
labor is spontaneously established. The entire uterus 
may be removed if the disease has not extended beyond 
the uterus and the condition of the mother permits. 

"When the disease is detected in the early months im- 
mediate panhysterectomy should be performed. 

Occlusion of the Os Externum. — The os is reopened 
by incision from behind forward. If the depression cor- 
responding to the os can be found with the finger, a small 
opening may be made with a knife and extended with 
scissors or stretched with the fingers or with a branched 
steel dilator. 

Tumors. Treatment. — (a) Vesical calculi may be re- 
placed, or, this being impossible, removed by vaginal 
lithotomy. 



256 ESSENTIALS OF OBSTETRICS. 

(b) Vaginal Tumors. — Removal, if practicable, is indi- 
cated, otherwise Csesarean section or the Porro operation. 

(c) Uterine Tumors. — Pedunculated tumors, when easily 
movable, may sometimes be pushed above the head with 
the aid of the genu-pectoral or the Trendelenburg posi- 
tion, or removed with ecraseur or scissors. The Csesarean 
or the Porro operation may be required. 

(d) Ovarian Cysts. — Generally ovariotomy is indicated 
immediately on discovery of the tumor. During labor 
reposition should be tried. Csesarean section is the only 
alternative when reposition fails. The tumor is removed 
at the same time. 

Development Anomalies of the Uterus. 

Uterus Unicornis. — One lateral half is absent ; there 
is generally but one Fallopian tube. This malformation 
arises from failure of development in one of Miiller's 
ducts. It is of special obstetric interest from the fact 
that the uterus sometimes has a rudimentary horn on the 
defective side in which pregnancy may occur. The con- 
dition is then very similar to tubal pregnancy. The 
rudimentary horn usually ruptures. Pregnancy in the 
developed horn of a uterus unicornis does not differ essen- 
tially from normal gestation. 

Uterus Didelphys. — A bifid uterus ; each lateral half 
forms a distinct organ, representing, however, but one- 
half of a uterus. The ducts of Muller, instead of fusing 
as they normally do to form the uterus, do not even come 
in contact with each other. The vagina may be single or 
double. 

Uterus Bicornis. — The lateral halves are distinct above, 
united below — the upper part of the uterus is bind. The 



PATHOLOGY OF LABOR. 257 

ducts of Miiller are developed, but are not united in the 
parts corresponding to the upper portion of the uterus. 
The uterine cavity is sometimes divided wholly or par- 
tially by a median septum. The vagina may be single or 
double. 

Uterus Cordiformis. — The fundus presents an antero- 
posterior median sulcus. 

Uterus Septus. — The uterine cavity is divided, wholly 
or partially, into two lateral cavities by a median partition. 
When the septum extends through the length of the uterus 
the condition is termed uterus septus duplex. When the 
division is incomplete we have a uterus subseptus. Ex- 
ternally the organ betrays no evidence of the abnormity. 
In all double uteri pregnancy may occur in either or both 
lateral divisions. Pregnancy in either causes the develop- 
ment of a decidua in each. 

C. ANOMALIES OF THE PASSENGER. 
Occipito-posterior Position. 

In most cases occipito-posterior positions terminate as 
anterior positions by rotation either above the brim, in the 
cavity or at the vaginal outlet. Exceptionally the sinci- 
put rotates to the pubes and the head is born with the 
face to the pubic arch. In this position the expelling 
forces act at a disadvantage ; the long diameter of the 
head does not conform fully to the axis of the pelvis and 
labor is impeded. In persistent posterior positions of the 
occiput the head not infrequently becomes arrested by im- 
paction in the pelvis. An impacted occipito-posterior 
position is one of the most formidable varieties of foetal 
dystocia. 
17 



258 ESSENTIALS OF OBSTETRICS. 

Causes. — The causes of auterior rotation of the sinci- 
put are : Imperfect flexion, bringing occiput and sinciput 
to the pelvic floor at about the same time ; defective re- 
sistance of the pelvic floor and consequent failure of the 
mechanism which normally shunts the occiput forward ; 
certain pelvic deformities, especially general contraction, 
oblique deformity and kyphotic pelvis, disturbing the 
normal mechanism. 

Diagnosis. Abdominal Signs. — No dorsal plane ; small 
parts in middle section of the abdomen ; cephalic prom- 
inence marked ; heart-tones heard over lateral aspect of 
abdomen well toward the back ; anterior shoulder remote 
from the median line. 

Vaginal Signs. — Large fontanelle easily accessible to 
the examining finger indicates either an occipito-posterior 
position or an imperfectly flexed anterior position. They 
are distinguished by the relative situation of the fonta- 
nelles and if necessary by palpating the ears with the 
hand in the vagina. 

Dangers. — The dangers in presistent occipito-posterior 
position are : To the mother, exhaustion, pelvic floor 
lacerations, the risks of operative interference ; to the child, 
those of prolonged labor. The foetal mortality is 15 per 
cent. In a relatively large pelvis the malposition is 
practically unimportant. 

Treatment, (a) Above the Brim. — Before rupture of 
the membranes the patient should lie in a lateral or latero- 
prone position on the side which the occiput confronts ; 
anterior rotation of the dorsum is thus often possible. 
The genupectoral position still more effectually helps the 
normal mechanism. 

Rotation failing, after sufficient dilatation correct the 



PATHOLOGY OF "LABOR. 259 

malposition by combined internal and external manipu- 
lation. One hand on the mother's abdomen pushes the 
anterior shoulder inward toward the median line ; fingers 
of the other passed into the uterus push the posterior 
shoulder of the foetus in the opposite direction. In this 
manner the child's dorsum, as well as the occiput, is 
brought to the front and there is no tendency to recurrence 
of the malposition. When the head alone is rotated it 
almost invariably reverts to its former position. By 
many authorities podalic version is preferred to the fore- 
going manoeuvre. 

(b) In the Cavity. — Anterior rotation of the occiput may 
be favored by keeping the patient upon the side to which 
the occiput looks, by upward pressure against the sinciput 
during the pains to promote flexion, sometimes by assist- 
ing rotation manually. If the head becomes arrested 
axis-traction forceps should be tried cautiously. 

When simpler measures fail the occiput may be rotated 
to the front with forceps. With a good grasp of the head 
over the parietal bones, the head is rotated by carrying 
the handles of the forceps well over to one thigh. Care 
must be used to keep the axis of the blades strictly 
in the axis of the pelvis during the manipulation. The 
head should be rotated through only a small arc of a 
circle at each effort thus allowing time for the trunk to 
follow. 

When the head is immovably fixed symphysiotomy 
may be considered. 

(c) At the vaginal outlet it is almost always possible to 
rotate the occiput into anterior position by backward 
pressure with the fingers against the anterior temple, com- 
bined if necessary with forward pressure upon the occiput. 



260 ESSENTIALS OF OBSTETRICS 

Only rarely must the head be delivered in the occipito- 
posterior position. 

Face Presentation. 

Frequency. — The frequency of face presentation is about 
one in two hundred and fifty labors. 

Causes. — The extension of the head probably is never 
primary ; it is developed during the labor. The causes 
are : Narrow pelvis, narrowing of the brim by prolapsed 
extremity, large child, enlargement of the neck or thorax, 
excessive uterine obliquity, pendulous abdomen, preter- 
natural mobility of the foetus owing to small size or to ex- 
cess of liquor amnii, impaction of the occiput in oceipito- 
posterior position. 

The preponderance of left niento-anterior positions is 
due to the right obliquity of the uterus. 

Mechanism. — The occipito-mental diameter is in rela- 
tion with the axis of the birth-canal, but that diameter is 
inverted, the head descending mental pole first. The 
values of the engaging diameters of the head are substan- 
tially the same as in vertex presentation. The difficulty 
of face births is due in the main to the fact that the thick- 
ness of the neck and a portion of the chest is added to the 
diameter of the face as the head descends, making a total 
diameter of 6 J inches. 

Positions : 

Left mento-anterior — L. M. A. 
Right mento-anterior — R. M. A. 
Right mento-posterior — R. M. P. 
Left mento-posterior — L. M. P. 

Mechanism of Mento-anterior Positions : Head Move- 
ments. 1. Extension. — This corresponds to flexion in 



PATHOLOGY OF LABOR. 261 

vertex births, bringing the occipito-mental diameter more 
nearly in relation with the axis of the pelvis. 

2. Rotation. — Rotation of the chin under the pubic 
arch unlocks the difficulty of face birth. Failure here is 
more serious than in vertex presentation. The mecha- 
nism of rotation is entirely similar to that in vertex births 
(mutatis mutandis). 

3. Flexion corresponds to extension in vertex presen- 
tation. The lower surface of the inferior maxilla rests on 
the margins of the ischio-pubic rami as pivotal points, 
and the head is expelled by a movement of flexion, face, 
forehead, vertex, and occiput sweeping in succession over 
the perineum. 

4. Restitution. 

5. External Rotation. — The explanation of these two 
movements is the same as in vertex births. The birth of 
the trunk follows the same mechanism as in vertex pres- 
entation. 

3Iechanism of Mento-posterior Positions. — In typical 
size of head and pelvis the birth of a persistent mento- 
posterior position is impossible, since it would necessitate 
the passage of a diameter of 6 J inches through the pelvis. 
Anterior rotation takes place in the majority of cases. 

Diagnosis. Abdominal Signs. — Hour-glass shape of 
the uterus ; cephalic tumor very round and filling one side 
of the pelvis only ; cephalic prominence in relation with 
the foetal dorsum, and generally on the same side of the 
median line with the breech ; sulcus at the junction of 
the head and back; heart and small parts on the same 
side ; inferior maxilla accessible to palpation. 

Vaginal Signs. — Orbital ridges ; nasal bones ; malar 
bones ; alveolar processes ; chin. 



262 ESSENTIALS OF OBSTETRICS. 

Prognosis. — Mento-anterior face cases and men to-pos- 
terior that rotate terminate spontaneously, as a rule, with 
little more danger to mother or child than vertex births. 
The more formidable difficulties of face birth arise chiefly 
from its complications. Disproportion between head and 
pelvis, prolapse of foetal members and failure of the pains 
are met with more frequently than in normal presentation. 
The total mortality is about 6 per cent, of the mothers and 
10 per cent, of the children. The face of the child at 
birth is usually much disfigured. 

The principal dangers to the mother are exhaustion 
and pressure-necrosis ; to the child, cerebral congestion 
from obstructed circulation in the veins of the neck. Ro- 
tation failing nearly all the children die. 

Treatment. — Nature is competent in most mento-an- 
terior positions and in most mento-posterior positions that 
rotate. In cases seen before engagement of the face, how- 
ever, or when the head can be pushed above the brim with 
the aid of the lateral, the knee-chest or the Trendelen- 
burg posture, as a rule the malpresentation should be 
corrected. In certain cases of posterior position it will 
be sufficient to reduce the position to an anterior one. 
The membranes should be preserved if possible until full 
dilatation. 

Mento-anterior Positions. — In the absence of complica- 
tions conversion into vertex, while permissible, is by no 
means imperative. These cases may generally be safely 
conducted as face births. Rotation is favored by keeping 
the patient on the side to which the chin points. Should 
the pains fail deliver with forceps. Since the conversion 
of a mento-anterior face case into a vertex presentation 
results in an occipito-posterior position, if this method be 



PATHOLOGY OF LABOR. 263 

chosen the operation should be supplemented by rotating 
the foetus into an anterior position. 

Head relatively large, or cord or arm prolapsed, poda- 
lic version is generally demanded. 

Mento-posterior positions not too firmly engaged should, 
as a rule, be converted into vertex presentations by one 
of the methods described below. Reduction of the posi- 
tion into a mento-anterior position may suffice in the ab- 
sence of complications. This usually is possible with the 
hand in the uterus, the trunk being rotated at the same 
time with the head. In disproportion between head and 
pelvis and in prolapse of the cord or an arm the same rule 
applies as in mento-anterior positions. 

When the face is too deeply engaged for reduction ro- 
tation may be favored by the lateral posture by promot- 
ing extension and by drawing the chin downward and 
forward during the pains. 

Forceps in mento-posterior positions of the face is one 
of the most difficult and dangerous of instrumental de- 
liveries, especially for the child, yet in skilled hands the 
use of forceps as a rotator is permissible. The technique 
is substantially the same, as in occipito-posterior position 
of the vertex. 

Face immovably fixed, foetus living, deliver by sym- 
physiotomy; foetus dead, by craniotomy. 

Methods for Converting Face into Vertex Presentation. 

1. Sehatz. — This consists in pushing the breech forward 
(toward the feet) with one hand, the chest backward and 
upward with the other, by external manipulation, and 
finally crowding the foetus downward in the axis of the 
pelvis. It is applicable only before rupture of the 



264 



ESSENTIALS OF OBSTETRICS. 



membranes and even then is not always practicable 
(Fig. 57). 

2. Baudelocque. — (1) Flexing the head by pushing up- 
ward with the fingers first against the chin, then the fossae 
caninae, then the brow, with one hand internally, the ex- 
ternal hand assists by forcing down the occiput. 

(2) Hooking down the occiput with the internal hand 
the external hand pushes up the chest. Anaesthesia is gen- 
erally required. 

3. Ziegempeck. — Baudelocque's first method may be 
combined with Schatz's, with the help of an assistant. 

Fig. 57. 




Schatz's method of reducing face to vertex presentation. 

The genu-pectoral or the Trendelenburg position greatly 
facilitates the foregoing manipulations. 

Brow Presentation. 

Brow presentation is a partial or semi-extension of the 
head. It is rarely met with, generally undergoing spon- 
taneous conversion into vertex or face. By many obstetri- 



PATHOLOGY OF LABOR. 265 

cians this anomaly is treated not as a distinct presentation, 
but as a variety of face presentation. 

The positions are those of face presentation. 

Causes. — The causes are substantially the same as in 
face presentation. 

The Frequency may be estimated at about 1 in 1,800 
labors. 

Diagnosis. Abdominal Signs. — The same as in face 
presentation but imperfectly developed. 

Vaginal Signs. — Orbital ridges within touch on one side, 
bregma on the other side, of the presenting part. 

Prognosis. — Delivery in persistent brow cases is impos- 
sible except with a relatively large pelvis. The maternal 
mortality is 1: 10 ; the foetal 1: 3. 

Treatment, (a) Conversion into Vertex. — Before engage- 
ment convert into vertex by seizing the head, pushing it 
up and hooking down the occiput, with the hand in the 
vagina and with the aid of anaesthesia. During the man- 
ipulation the fundus is supported by firm pressure with 
the external hand. Pressure upon the occiput, applied 
through the abdominal wall, helps. 

(6) Conversion into face by traction on the upper max- 
illa with the fingers. This is not admissible in mento- 
posterior positions. 

(c) Version for rapid delivery, if indicated in the inter- 
est of mother or child and the head is not engaged or the 
uterus is not firmly contracted. 

(d) Symphysiotomy in impacted and irreducible brow 
presentation if child is living and viable, if dead crani- 
otomy. 

In general the same principles apply as for the man- 
agement of face births. 



266 ESSENTIALS OF OBSTETRICS. 

Breech Presentation. 
Varieties. — Three varieties of breech presentation are 
recognized according to the part of the pelvic extremity 
which presents — breech, knee and footling. The distinc- 
tion is of no practical importance, so far as the mechanism 
is concerned. In certain cases, however, as will be seen, 
it affects the question of treatment. 

Frequency. — Exclusive of premature labors, the fre- 
quency of breech presentation is about 1 in 60 births. 

Causes. — The causes are : Narrow pelvis, tumors of the 
uterus, placenta prsevia, hydrocephalus, multiple foetus 
and conditions favoring the mobility of the foetus, such as 
multiparity, prematurity, lax uterine walls, hydramnios, 
shape of the uterus possibly, small foetus. 

Mechanism. — Usually the bisiliac diameter engages in 
one of the oblique diameters of the pelvis. We have, 
therefore, four 
Positio7is : 

Left sacro-anterior — L. S. A. 
Right sacro-anterior — R. S. A. 
Right sacro-posterior — R. S. P. 
Left sacro-posterior — L. S. P. 
Rotation in breech is not so pronounced as in head pres- 
entation. As the breech descends the posterior hip first 
lands upon the pelvic floor and first appears at the vulva. 
The shoulders rotate more or less completely. The head 
rotates as perfectly as in vertex births. In dorso-pos- 
terior positions the occiput, as a rule, comes eventually 
to the front. The nape of the neck resting against the 
pubic arch, the head is expelled by a movement of flexion 
around this as a pivot, the face, the forehead and the 
vertex successively sweeping over the perineum. Spon- 



PATHOLOGY OF LABOR. 267 

taneous expulsion of the after-coming head, however, is 
exceptional. 

In persistent do )' so -posterior positions the head is gener- 
ally delivered by a movement of rotation about the pos- 
terior edge of the vulvar orifice, mental pole first as in an- 
terior positions. If the chin catches upon the pelvic brim 
delivery is accomplished occiput first. In this method of 
expulsion the lower surface of the inferior maxilla pivots 
against the pubic bones, and occiput, vertex, forehead and 
face sweep in succession over posterior vulvar commissure. 

Diagnosis. Abdominal Signs. — 1. Fundal pole hard, 
globular, susceptible of ballottement, sulcus between it 
and the trunk ; 

2. Lower pole irregular in shape, not so hard, in primi- 
parse above the excavation before labor. 

When the head is in the lower uterine segment ballotte- 
ment is possible only in multiparas and with excess of 
liquor amnii ; even then it is imperfect. In primiparse in 
the absence of pelvic contraction and of obstruction from 
tumors or other causes, the head, when it presents, is found 
in the excavation. 

Vaginal Signs. — Glove-finger protrusion of the bag of 
waters ; obviously this can be present only after labor has 
been for some time established. 

Absence of the hard globular head ; 

Absence of fontanelles and sutures ; 

Ischial tuberosity ; 

Tip of the coccyx, anus, genitals, on a line bisecting the 
bisischial line at a right angle. 

Femora ; 

Expulsion of meconium — not diagnostic ; it is some- 
times observed in cephalic births. 



268 ESSENTIALS OF OBSTETRICS. 

Frequently both ischial tuberosities may be reached, 
and from them the femora be traced for a short dis- 
tance. 

Identify a foot or knee by its anatomical characters. 

In differentiating between head and breech do not rely 
on a mere casual touch. Every accessible part of the 
presenting pole must be searched minutely, and with firm 
pressure if impacted in the excavation and its bony land- 
marks obscured by cedematous swelling of the overlying 
soft structures. 

Prognosis. To the Mother. — The first stage of labor may 
be more tedious. The second stage is often more rapid. 
In artificial delivery laceration of the cervix occurs more 
frequently than in vertex births ; in first labors at least 
laceration of the pelvic floor is the rule. The danger to 
life is not increased. 

To the Child. — The mortality, when the delivery is left 
to nature, is one in three or four; with skilled manage- 
ment it is but little greater than in vertex births. 

The cause of the foetal mortality is asphyxia from im- 
peded blood-supply due to retraction of the uterus after 
the birth of the trunk, and from compression of the funis 
after the head engages. The foetal mortality is increased 
in dry labor. 

Indications of danger to the child at the critical moment 
in breech delivery, are : funic pulse irregular and feeble, 
occasional gasping respiratory efforts, convulsive move- 
ments of the limbs. 

Treatment. Before Labor. — External version is permis- 
sible if it can be done without violence. While conver- 
sion into vertex presentation is desirable, the indication 
for changing the presentation before labor is not sufficiently 



PATHOLOGY OF LABOR. 269 

urgent to justify the risk involved in a difficult external 
version. 

During Labor, (a) Delivery of the Trunk. — The danger 
to the child arises chiefly from the difficulty of delivering 
the after-coming head before the child perishes from arrest 
of the utero-placental circulation by compression of the 
umbilical cord. Undelivered the child will almost surely 
die within five minutes after the head engages and the 
utero-placental circulation is cut off. The delivery of 
the after-coming head is facilitated by : (1) Ample dilata- 
tion of the passages ; (2) full flexion of the head, which 
also tends to maintain the flexion of the arms. 

Promote 1 by preserving the membranes till they reach 
the pelvic floor and, as a rule, by a slow and gradual de- 
livery of the breech ; maintain 2 by avoiding traction till 
the trunk is delivered, or, when traction is unavoidable, 
by external manipulation so applied by a skilled assistant 
as to keep the chin firmly pressed against the chest. 

Bringing Down a Foot. — When the case is seen before 
the breech has engaged too firmly in the excavation one 
foot should be brought down. This is done as a precau- 
tion against arrest of the breech in the pelvis. The leg 
serves as a tractor should the expellent forces fail. 

(6) Delivery of the Arms and Head. — Preliminaries. 
The patient, as a rule, should be under an anaesthetic. 
Have the forceps ready. See that a flannel or towel is in 
readiness for wrapping the child's body as soon as it is 
expelled, to help to prevent premature efforts at respira- 
tion. Watch the pulsation of the funis for warning of 
danger to the child. Pull the cord down and dispose it 
if possible in that part of the pelvis which offers the most 
room. 



270 ESSENTIALS OF OBSTETRICS. 

Extraction of the Arms, (a) Arms Flexed. — Bring them 
down with the hand passed along the child's abdomen. 

(b) Arms Extended. 1. Delivery of the First Arm. — As 
soon as the shoulder-blade can be reached easily, grasp 
the feet and draw the trunk to the side opposite the occi- 
put. Bring down the posterior arm first. Pass the free 
hand up along the child's back and slip one or two fingers 
over the shoulder and along the humerus to the elbow. 
Sweep the elbow in a circular direction across the face 
and down. Beware of applying the force at the middle 
of the humerus and of attempting to bring the arm 
straight down, lest the humerus be fractured or the 
shoulder-joint injured. 

2. Delivery of the Second Arm. — Bring the child's trunk 
into the long axis of the mother's body, seize the trunk 
with both hands and push it up to release the head and 
extended arm from the grasp of the pelvic brim ; rotate 
the trunk, if necessary, to carry the undelivered arm op- 
posite the nearest saero-iliac joint. Assist rotation by 
drawing the delivered arm gently across the child's back. 
Then, holding the trunk to the opposite side, bring down 
the second arm, sweeping the elbow inward across the face 
and downward as in case of the first arm. It is seldom 
that rotation of the head fails by twisting the trunk as 
above described. Should it do so from the fact that the 
head has been driven too far into the pelvis the manoeuvre 
mentioned by Kehrer may be tried. This consists in 
pushing the occiput outward with the external hand 
while the face is swept inward with the arm by the in- 
ternal hand. 

Extraction of the After-coming Head. I. Dor so-anterior 
Positions. — Seizing the trunk again with both hands rotate 



PATHOLOGY OF LABOR. 



271 



the head, if necessary, to bring the face opposite one of 
the sacro-iliac joints. 

Smellie-Veit (Mauriceau) Method. — Two fingers of one 
hand are passed within the passages and held firmly 
against the fossae canine or the inferior maxilla to main- 
tain complete flexion. Two fingers of the other hand are 
hooked over the shoulders astride the neck. The child's 



Fig. 58. 




The Sruellie-Veit method of extracting the after-coming head. (Doderleix.) 

trunk lies on the operator's forearm. The head is 
delivered by traction. The natural mechanism must be 
observed, keeping the long diameter of the head in the 
oblique diameter of the pelvis till past the brim . As the 
chin approaches the fourchette a finger introduced into 
the mouth depresses the tongue for the admission of air. 



272 ESSENTIALS OF OBSTETRICS. 

Expressio foetus by a skilled assistant is an important aid 
in bringing the head through the pelvis. (Fig. 58.) 

Wiga ad-Martin Method. — Of manual manoeuvres this 
is the most efficient when the operator must work with- 
out assistance. The technique is as follows : Two fingers 
of one hand are placed in the child's mouth or pressed 
against the fossa? caninse to control the mechanism, es- 

Fig. 59. 



The Wigand-Martin method of delivering the after-coming head. (Doderleix.) 

pecially to maintain full flexion. With the other hand 
the head is driven through the pelvis by powerful supra- 
pubic pressure. (Fig. 59.) 

Forceps. — An assistant seizing the child's feet holds its 
body well up over the mother's abdomen. The forceps 
is then applied to the head. This is the most reliable of 
all methods of extracting the after-coming head. Observ- 
ing the normal mechanism and avoiding violence, the 



PATHOLOGY OF LABOR. 273 

danger of maternal injuries is no greater than in manual 
extraction. 

II. Dor so-posterior Positions. — On expulsion of the body 
rotate the occiput to the front by gentle torsion of the 
trunk and with the aid of external pressure applied 
over the mother's abdomen by an assistant. Then de- 
liver as in primary anterior positions. Rotation failing, 
deliver by traction and suprapubic pressure, carrying the 
trunk downward and backward over the perineum. 
Should the chin catch over the brim of the pelvis, deliver, 
occiput first, by traction upon the body directed upward 
and forward over the pubes, aided by suprapubic pressure 
or by the forceps. 

Nuchal Arm. — Should the forearm of the foetus be 
lodged behind the neck, rotate the body in the direction 
from the misplaced arm guarding against too much tor- 
sion of the neck. The rotation of the head may, if neces- 
sary, be assisted by external pressure. Sometimes the 
nuchal arm may best be dislodged with the hand in the 
passages. Having disengaged the arm, proceed as in or- 
dinary cases. 

In Failure of the Poivers at or above the Brim one or 
both feet should be brought down, if this is possible 
without violence. With the aid of postural measures the 
breech may be dislodged from the brim after partial en- 
gagement. 

When the legs are extended, carrying the feet high up 
in the uterus, the foot may be brought down as follows : 
Passing two or three fingers into the uterus between the 
thighs, one thigh is pressed outward ; the knee is thus 
flexed and the foot brought down within reach of the op- 
erating hand. 
18 



274 ESSENTIALS OF OBSTETRICS. 

Impaction, or Failure of the Powers in the Cavity. — 
Three methods are available for delivery, traction by fin- 
ger, fillet, forceps. 

The finger hooked in the groin is competent when only 
a moderate amount of force is required. 

The fillet. A yard of strong muslin bandage or a soft 
handkerchief may be used as a fillet. It is oiled and 
knotted at one end. The knot is pushed up over the 
groin with one hand and hooked down on the opposite 
side of the thigh with the fingers of the other hand. 
Traction is then applied to the fillet with care to avoid 
doing violence to the structures of the groin by too great 
pressure. 

In dorso-posterior positions the fillet is made to encircle 
the pelvis, the free ends depending between the thighs. 
One end is passed over each groin from without inward 
and the loop slipped up over the sacrum. Or the fillet 
may be passed over one groin and be held in place with one 
hand while traction is made with the other. The latter 
precaution is necessary owing to the danger of fracturing 
the femur should the fillet slip and traction be made upon 
the central portion of the shaft. 

Forceps. — In cases not manageable by the finger or the 
fillet forceps may be applied to the breech. One blade is 
placed over the sacrum and ilium, the other over the pos- 
terior surface of the opposite thigh, or the blades are ad- 
justed over the trochanters, especially in dorso-posterior 
positions, avoiding pressure upon the ilia. Moderate trac- 
tion is made and assisted with expressio fwtus. 

The cephalotribe, applied to the breech, may be used to 
advantage if the foetus is dead. 



PATHOLOGY OF LABOR. 275 

Transverse Presentation : Shoulder Presentation. 
A transverse presentation is one in which the long axis 
of the foetal ellipse lies across the long axis of the uterus. 
The presentation, however, is oblique rather than trans- 
verse. In a large proportion of cases cross presentations 
are spontaneously converted into longitudinal when labor 
begins. In persistent tranverse presentation the shoulder, 
or sometimes the arm, becomes the presenting part after 
labor is established. 

Frequency. — The frequency of shoulder presentations 
has been variously estimated, but may be fairly stated as 
1 in 250. 

Causes. — The causes of cross-birth, which is a partial 
inversion of the foetal axis, are practically the same as 
those of breech-birth or complete inversion. This anomaly 
is therefore observed most frequently in unusual mobility 
of the foetus, twin pregnancy, foetal tumor, myoma of the 
lower uterine segment, undue pelvic inclination, pelvic 
deformity, and low attachment of the placenta. 

Positions. — Since the child's head may lie either to the 
right or the left of the mother, and its back may be turned 
anteriorly or posteriorly, there are four possible positions 
in cross-births, as follows : 

Left scapuloanterior — L. Sc. A. 

Right scapuloanterior — R, Sc. A. 

Right scapulo-posterior — R. Sc. P. 

Left scapulo-posterior — L. Sc. P. 
It should bb noted that these positions are named ac- 
cording to the direction of the presenting scapula, When 
the scapula looks to the left and front the position is a 
left scapulo-anterior, when to the right and front it is a 
right scapulo-anterior position, and so on. 



276 ESSENTIALS OF OBSTETRICS. 

Diagnosis. Abdominal Signs. — Absence of both foetal 
poles from the excavation after labor is established ; 

Presence of the head in one or the other iliac fossa. 

Vaginal Signs. — Glove-finger protrusion of the bag of 
waters ; 

Presenting part smaller, more yielding and less distinctly 
rounded than the hard globular head ; 

Especially significant is absence of any presenting part 
at the onset of labor ; 

After labor is well established the presenting part is a 
small, rounded prominence ; it is distinguished from an 
ischial tuberosity by the absence of a companion ; from it 
run the humerus, the clavicle and the spine of the scapula 
in radiating lines ; 

The neck is felt on one side of the presenting part, the 
ribs on the other ; 

The axilla can be made out ; 

The elbow is identified by the olecranon. 

The position is determined by the location of the scapula 
to the right or left, anteriorly or posteriorly. The axilla and 
the elbow look toward the feet ; the thumb toward the head. 

When an arm is prolapsed distinguish hand from foot, 
and the right from the left hand. Shake hands with the 
foetus ; the right hand of the examiner fits the right hand 
of the foetus, and vice versa. 

Prognosis. — In persistent transverse presentations one 
in ten of the mothers and half the children die. The 
risks to the mother are from pressure-effects, exhaustion, 
sepsis, rupture of the uterus ; to the child, from pressure- 
effects, prolapsus funis. 

Spontaneous Delivery. — Very rarely spontaneous de- 
livery takes place in one of the following methods : 



PATHOLOGY OF LABOR. 277 

(«) Spontaneous Version. — The shoulder presentation is 
converted into a breech or into a vertex birth by the 
uterine expulsive efforts. Such a change of presentation 
is common at the beginning of labor. It occurs more 
frequently in multipara than in priinipara, oftener with 
a living than with a dead child. 

(b) Spontaneous Evolution. — The mechanism of sponta- 
neous evolution is as follows : As the child is driven 
down by the uterine contractions the head rides over the 
symphysis and the anterior shoulder becomes fixed under 
the pubic arch. The other shoulder is forced down over 
the posterior wall of the pelvis and is expelled first. It 
is then followed by the trunk. The head is born last. 

Expulsion tvith trunk doubled on itself may occur when 
disproportion between the size of the pelvis and foetus 
favors. It is almost surely fatal to the child. 

Treatment. Before Labor. — Correct the malpresenta- 
tion by external cephalic version. To retain apply an 
abdominal binder and lateral compresses. 

During Labor. — Preserve the membranes ; evacuate 
the bladder and rectum ; note capacity of the pelvis, size 
of the child, situation of the retraction ring and the de- 
gree of thinning of the lower uterine segment. Perform 
version, cephalic or podalic, by the bipolar or the internal 
method, under anaesthesia. Reduction of the malpresen- 
tation is often possible with the aid of the genu-pectoral 
or the Trendelenburg position. In impacted and irredu- 
cible shoulder presentation decapitation will be required. 

Treatment of Complex Presentations. 
Head, and Hand. — When possible replace the hand ; 
this failing, deliver with forceps, placing the arm in the 



278 ESSENTIALS OF OBSTETRICS. 

unoccupied side of the pelvis, or, better, perform podalic 
version. 

Hand and Foot or Head, Hand and Foot. — Extract 
by one or both feet. 

Nuchal Arm. — The diagnosis is made by anaesthetiz- 
ing the patient and introducing the hand into the passages. 

In vertex presentation the arm is dislodged with the 
hand in the uterus by rotating the body from the nuchal 
arm. Rarely version will be necessary. 

In head-last cases the nuchal arm is dislodged by seiz- 
ing the delivered trunk with both hands and rotating the 
body from the misplaced arm. The other arm should 
first have been delivered. The reduction of the misplace- 
ment may be followed, if necessary, by introducing two 
fingers between the shoulder and the symphysis and 
bringing down the arm in the manner practised in ordi- 
nary breech extraction. 

In complex presentation, if the foetus is dead, delivery 
is best accomplished, as a rule, in the interest of the 
the mother, by craniotomy. 

ANOMALIES OF F(ETAL DEVELOPMENT. 

Twins. 

Relative situations of twins are : one above the other, 
one beside the other, one in front of the other. 

Diagnosis, (a) Abdominal Signs. — Excessive size and 
tension of the uterine tumor ; permanent tension of the 
tumor, with very limited mobility of the contents, should 
suggest twins ; 

Shape of the tumor ; excessive width, a longitudinal 
sulcus ; the latter, however, is not diagnostic ; 



PATHOLOGY OF LABOR. 279 

Suprapubic oedema ; this is present also in simple 
hydramnios ; 

Multiplicity of small parts ; 

Two dorsal planes ; 

Three or four fetal poles ; 

One head in the excavation and one in the upper uterine 
segment ; 

One head in the excavation and one in the iliac fossa ; 

Distance from the pelvic pole to the fundal pole over 
30.5 cm., 12 inches ; 

Two foetal heart-sounds of different rates ; 

Two foetal heart-sounds of the same rate, but in widely 
different situations and on opposite sides of the abdomen ; 

Heart tones above the umbilicus and head in the exca- 
vation. 

(6) Vaginal Signs. — A rapidly successive presentation 
of a head and a breech ; 

Four extremities offering at the brim ; 

Two amniotic bags presenting. 

Management of Labor in Twin Births. — The manage- 
ment of labor in twin births differs in nowise essentially 
from that of ordinary labor. The cord of the first child 
should be ligated on the placental as well as the foetal 
side, owing to the possible existence of a vascular com- 
munication between the two placentae. Since the passages 
are dilated by the birth of the first child, the second birth, 
except when the first child is undersized, is usually rapid, 
or, if necessary, may safely be made so. The delivery 
of the second child, however, should be left to nature ex- 
cept for cause. The foetal heart should be watched. As 
the over-distention of the uterus exposes the woman to 
post-partum hemorrhage, extra care will be needed to 



280 ESSENTIALS OF OBSTETRICS. 

secure firm uterine retraction by manipulation and by 
the use of ergot. 

Interlocking Twins. 

This anomaly, which is exceedingly rare, presents two 
principal 

Varieties. — («) Both presentations cephalic, both heads 
offering, one impacted between the head and trunk of the 
other foetus. 

(6) One presentation cephalic, one pelvic, the after- 
coming head of the breech birth being impacted between 
the head and trunk of the other foetus. 

Management. — Disengage by a combined internal and 
external manipulation, with the aid of the knee-chest or 
the Trendelenburg position. The first child may be de- 
capitated as a last resort. 

Double Monsters. 
Premature and spontaneous delivery is the rule. In 
most cases delivery will be facilitated by podalic version 
if the diagnosis is made in time to operate early in the 
labor. Resort should be had to embryotomy in difficult 
cases. 

Hydrocephalus. 

Hydrocephalus is attended with a serous effusion into 
the cranial cavity with consequent enlargement of the 
cranial vault. The effusion is usually found in the ven- 
tricles, very rarely in the arachnoid or subarachnoid cavity. 

The quantity of fluid may be several pints. Spina 
bifida and other anomalies of development frequently co- 
exist. The etiology is obscure. Syphilis and alcoholism 
are among the causes assigned. 

Diagnosis, (a) Head-first 



PATHOLOGY OF LABOR. 281 

Abdominal Signs, — The best diagnostic evidence is af- 
forded by measurement of the head as determined with a 
pelvimeter through the abdominal walls or estimated by 
palpation. Mensuration of the head by this means may 
be impossible owing to hydramnios. 

Vaginal Signs. — Size, elasticity and fluctuation of the 
cranial vault ; excessive width of the sutures ; the latter, 
however, is not peculiar to hydrocephalus ; 

Fontanelles preternaturally large ; 

Sometimes a supplementary fontanelle between the an- 
terior and the posterior ; 

Unnatural prominence of the frontal and parietal bones. 

The size of the head cannot be estimated by the usual 
method of vaginal examination, which explores only the 
presenting part. Elasticity and fluctuation are not always 
readily detected when the cranial vault is rendered tense 
by firm engagement in the pelvic brim. When in doubt 
the patient should be placed under an anaesthetic and the 
hand introduced into the uterus. 

(b) Head-last Cases. — In one case in three the hydro- 
cephalic foetus presents by the breech. The signs of 
hydrocephalus in breech birth are : 

Body wasted ; 

Head arrested after the birth of the trunk ; 

The size of the head as determined by measurement or 
by palpation through the abdominal wall. 

Prognosis. Child. — The mortality is over 80 per cent.; 
even if the child is born alive it is of feeble viability ; 
nearly all die soon after birth. 

Mother. — The mortality is estimated at 18 per cent., 
from exhaustion, rupture of the uterus, hemorrhage. 

Treatment. — The delivery may be left to nature or may 



282 ESSENTIALS OF OBSTETRICS. 

be effected by version or perforation, according to the 
degree of obstruction. Version, however, is seldom avail- 
able, owing to danger of uterine rupture, Aspiration of 
the cavity with a small trocar passed through a fontanelle 
or suture may often be substituted with advantage for 
craniotomy. The life of the child is not necessarily lost 
by drawing oif the fluid. The forceps is not applicable ; 
the grasp is insecure. When the head has been perforated 
the cephalotribe is the most efficient tractor. 

In difficult head-last cases the head may be perforated 
or the spinal canal opened and the cranial cavity cathe- 
terized through it. The perforator can be passed safely 
beneath the skin, entering it over the neck. 

Serous effusions into other cavities, if they cause marked 
dystocia, are to be evacuated by aspiration of the dropsical 
cavities or by free incision. 

Tumors. 

Hygroma, fibroma, lymphangioma, myoma, sacro-coccy- 
geal teratoma, spina bifida, enlargement of abdominal vis- 
cera and other tumors are occasionally met with. 

Treatment. — Delivery of the foetus intact being impos- 
sible, fluid tumors may be reduced by tapping or by in- 
cision, solid, by segmentation. 

ANOMALIES OF LABOR ARISING FROM ACCI- 
DENTS OR DISEASE. 

Prolapsus Funis. 
In prolapsus funis a loop of the navel cords slips down 
in advance of the presenting part of the foetus. As the 
labor goes on the misplaced portion of the cord is com- 



PATHOLOGY OF LABOR. 283 

pressed between the part presenting and the walls of the 
birth canal, and without relief the foetus dies usually 
within five minutes from the interruption of the feto- 
placental circulation. 

Frequency. — Prolapse of the cord occurs once in about 
two hundred and fifty labors. 

Causes. — Anything which prevents the presenting part 
from completely and continuously filling the lower uterine 
segment predisposes to prolapsus funis, e. g.: 

Hydramnios ; 

Deformed pelvis ; 

Malpresentation (frequency in head presentation, 1 in 
304; face, 1 in 32; pelvic, 1 in 21 ; shoulder, 1 in 12); 

Complex presentations ; 

Twins ; 

Small foetus ; 

Multiparity ; 

Pendulous abdomen ; 

Uterine myomata ; 

Low placental insertion ; 

Kupture of the membranes while the woman is stand- 
ing. 

Marginal insertion of the cord, or 

Excessive length of the cord may favor prolapse. 

Diagnosis. — The prolapsed cord may be found in the bag 
of waters, in the vagina, or protruding through the vulva. 
Before rupture of the membranes distinguish from fin- 
gers and toes by the anatomical characters of the latter. 
The foetal parts will usually be drawm up out of the way 
when touched. After rupture of the membranes the diag- 
nosis presents no difficulty. 

Prolapse of the cord must be distinguished from pro- 



284 ESSENTIALS OF OBSTETRICS. 

trusion of a loop of intestine following rupture of the 
uterus. In the latter there is more or less hemorrhage, 
the prolapsed loop is larger, the mesentery can be felt, 
and pulsation is absent. The prolapsed part of the cord 
should be examined for the funic pulse to learn whether 
the child is living. Absence of pulsation for fifteen 
minutes may be taken as evidence of the death of the 
foetus. Listen for the foetal heart over the abdomen. 

Prognosis. — The prolapse itself entails no additional risk 
to the mother ; the conditions which give rise to it and 
operative measures necessitated by it may do so. 

The foetal mortality may be stated at 50 per cent. It 
is highest in vertex presentations and in first labors. The 
danger is much increased after the membranes rupture. 

Treatment. Before Rupture of the Membranes. — Of 
first importance is the preservation of the membranes if 
still unbroken. It should be a rule to rupture them in 
no case intentionally without first examining for possible 
prolapse of the cord. Keep the patient in the lateral or 
latero-prone position. Place her on the side opposite 
that on which the cord came down in the hope that the 
displaced loop may return by its own weight. Push cord 
up between the pains, with care to avoid rupturing the 
membranes. Crowd the presenting part down and guard 
against recurrence of the displacement till the presenting 
part has firmly engaged. Listen at short intervals over 
the abdomen for the foetal heart. 

After Rupture of the Membranes. — Reposit at once if 
the funic pulse can be felt ; if the pulsation has ceased, 
but the heart-tones are still audible, push up the present- 
ing pole and replace the cord after pulsation returns. 

Dj not subject the mother to the discomfort and the 



PATHOLOGY OF LABOR. 285 

risks of reposition till assured that the child is living 
and viable. 

Methods, (a) Manual Reposition. — Place the patient 
in the latero-prone or the genu-pectoral or the Trendelen- 
burg posture. Anaesthesia is generally necessary. Twist 
the prolapsed loop loosely into a rope and push it up an- 
teriorly, operating between the pains. Much handling of 
the cord is dangerous to the child ; it enfeebles the foetal 
heart. To retain, crowd the presenting pole firmly into 
the excavation and hold it there by manual pressure or 
with an abdominal binder. Let the patient lie in the 
latero-prone position, with the hips elevated, or in the 
Trendelenburg position. Examine through the vagina 
from time to time, lest the cord slip down again as the 
labor progresses. 

Listen frequently for the strength and rate of the foetal 
pulse. 

(b) Instrumental Reposition. — The aid of posture is 
essential, as in the manual method. An instrumental re- 
positor is substituted for the hand. An English catheter, 
with a tape attached and loosely looped over the cord, 
makes an easily improvised and efficient repositor. After 
complete reposition the catheter may be left in the uterus. 
The instrument is armed with a stylet, which is with- 
drawn after replacing the cord. Measures for retention 
are to be used as in the manual method. 

(c) Forceps or Breech Extraction. — Should all attempts 
at reduction and retention fail, sometimes the child may 
be saved by rapid delivery. This is possible in vertex 
presentation with forceps or by version ; in breech cases, 
by the usual technique of breech extraction. The cord, 
meanwhile, should be disposed where it will receive the 



286 



ESSENTIALS OF OBSTETRICS. 



least pressure, opposite the sacro-iliac joint in the side of 
the pelvis in which there is most room. It is sometimes 
best to resort to version primarily. 

Inversion of the Uterus. 
The inversion may be complete or partial. It begins 
usually as a cup-shaped depression at the fundus. (Fig. 
60.) In the vast majority of cases it occurs just before, 
rarely directly after, the expulsion of the placenta. 

Fig. 60. 




Three stages of inversion : 1. Cup-shaped depression of fundus. 2. Partial in- 
version. 3. Complete inversion, a, fundus uteri; b b, cavity; c, vagina; dd } 
mouth of inverted portion . 

Frequency. — The frequency of puerperal inversion of 
the uterus may be estimated roughly at 1 : 100,000 to 
1 : 150,000. In properly conducted labors the accident 
is well-nigh impossible. 

Etiology. — Relaxation of the uterus in the third stage 
of labor is the primary cause. Unskilled pressure on the 
fundus, traction on the cord while the uterus is relaxed, 
or a fundal placental seat may contribute to the ac- 
cident. 

Diagnosis. Symptoms. — Complete inversion of the 
uterus is followed by shock, pain, hemorrhage and gener- 



PATHOLOGY OF LABOR. 287 

ally b) T vesical and rectal tenesmus. Exceptionally both 
the hemorrhage and the pain may be insignificant. 

Physical Examination. — The bladder and the rectum 
should be empty. In partial inversion of the uterus a 
cup-like depression can be felt at the fundus by abdom- 
inal touch. Complete inversion is recognized by the ab- 
sence of the usual abdominal tumor as made out by 
palpation or by abdomino-vaginal or abdomino-rectal ex- 
amination, by the presence of a vaginal tumor and by the 
character of the tumor. 

The inverted uterus is distinguished from a peduncu- 
lated fibroid by its special contractility, by its large ped- 
icle and by greater pain and greater immobility on at- 
tempting torsion. In case of a polypus depending 
through the cervix a sound may be passed alongside the 
tumor into the uterine cavity, yet differentiation is some- 
times difficult. It should be remembered that the placenta 
may still be adherent. 

Prognosis. — Without prompt reposition the prognosis is 
extremely grave. The mortality, even in skilled hands, 
is one-fifth to one-third, from hemorrhage, shock, peri- 
tonitis, gangrene of the uterus, septicaemia. 

Treatment. — The preventive treatment depends on the 
proper management of the placental stage of labor. Stim- 
ulate prompt and persistent retraction, meantime holding 
the anterior firmly against the posterior wall of the uterus 
by pressure over the abdomen. 

Methods of Reposition : 

(a) Simple Cases. — Immediately after inversion reduction 
is seldom difficult. The patient having been anaesthetized, 
the operator places one hand on the abdomen over the in- 
verted uterus for counter-pressure, using the fingers at the 



288 ESSENTIALS OF OBSTETRICS. 

same time for dilatation of the cervical ring ; he cones the 
fingers of the other hand, and, passing them into the 
vagina, applies the finger-tips to the fundus. Sometimes 
the pressure is best made over the insertion of one Fal- 
lopian tube ; sometimes over the central portion of the 
fundus. The fundus once fairly indented complete re- 
duction is easily effected. The force must be directed to 
one side of the sacral promontory. 

Another method consists in pressing the fundus upward 
with the palm of the hand while two or more fingers in- 
dent the lateral wall of the uterus. 

When the placenta is adherent replace all ; when it is 
partially detached separate and remove it before trying 
taxis. 

(6) Difficult Cases. — Taxis may be tried with the aid of 
posture. This failing, recourse may be had to elastic 
pressure applied with a water-bag, alternated with taxis. 
Leave the bag in place for about eight hours, then remove 
it and repeat the taxis. Failing, apply the water-bag 
again for another eight hours. Rigorous precautions must 
be observed to prevent infection. Extreme measures are 
inadvisable during the puerperium, and attempts at repo- 
sition should be deferred for several weeks if not success- 
ful within twenty-four hours. 

RUPTURE OF THE UTERUS. 

Nature of the Accident. — Usually the tear begins in the 
lower segment. It may take any direction and reach any 
extent within the limits of the organ. The vagina or the 
bladder may be involved. The portio vaginalis is some- 
times torn off. Fissures of the cervix of greater or less 
depth occur in most labors. 



PATHOLOGY OF LABOR. 



289 



The rupture is said to be complete when it extends 
from the uterine into the peritoneal cavity ; otherwise it 
is incomplete. 

Incomplete rupture not infrequently takes place into 
one of the broad ligaments. Spontaneous rupture occurs 
very seldom during pregnancy, most frequently toward 
the end of the first stage of labor. (Fig. 61.) 

Fig. 61. 




Rupture of the uterus. (Schaeffer.) 
PI. Placental site. RR. Retraction ring. Ru. Seat of rupture. Vag. Yagiua. 

Frequency. — This accident occurs in 1 in about 4,000 
labors. It is less frequent in first than in subsequent 
births. 

Etiology, (a) Predisposing Causes. — Local lesions of 
the uterine muscle ; examples are carcinoma, myoma or 
19 



290 ESSENTIALS OF OBSTETRICS. 

the cicatrix of an old laceration or of Cesarean section 
not properly sutured. Pressure between the head and a 
sharp bony prominence, as the sacral promontory or an 
exostosis, may contribute to the accident. The chief pre- 
disposing cause is obstructed labor, with excessive thin- 
ning of the lower uterine segment. 

(b) Exciting Causes. — Abuse of ergot and operative 
violence, such as forceps in an undilated os, version in a 
firmly contracted uterus, are prominent exciting causes. 
Diagnosis. — Danger signals are : 

Evidence of obstruction with violent uterine con- 
tractions ; 
Tenseness of the round ligaments ; 
Excessive retraction of the uterus as shown by high 
position of the retraction ring, more than half- 
way to the umbilicus ; 
Preternatural pain and restlessness ; 
Abdomen over-sensitive to pressure. 
Signs of Rupture : 

Sense of tearing ; 

Abrupt cessation of labor pains, in complete rup- 
ture ; 
Persistent uterine pain ; 

Hemorrhage — external, retroperitoneal, intraperi- 
toneal ; 
Collapse in proportion to the amount of blood-loss a 
Presenting part absent or receding ; 
No evidence of foetal life ; 
Knuckle of intestine in the uterus ; 
Uterus and the child forming separate tumors. 
The diagnosis is confirmed on examining with the fin- 
gers in the uterus. 



PATHOLOGY OF LABOR. 291 

Prognosis. — In complete rupture the mortality for the 
mothers is 90 to 95 per cent., from hemorrhage, peritoni- 
tis, septicaemia. The foetal mortality is even greater from 
complete interruption of the utero-placental circulation. 

Treatment. — 1. Preventive. — The cause of obstruction 
should be removed if possible ; malpositions should be 
corrected. In excessive retraction of the uterus immedi- 
ate delivery is indicated, as a rule, even though it neces- 
sitate embryotomy. 

2 . Curative. Incomplete Rupture. — If the i nj ury is co n - 
fined to the upper uterine segment, the child and placenta 
being delivered, the treatment should be expectant. 
Hemorrhage is controlled by firm uterine contraction. 
Subperitoneal laceration of the cervix and lower uterine 
segment is attended with the formation of a more or less 
extensive hseroatoma. The blood-clot should be removed 
and the wound-cavity packed with iodoform gauze. Per- 
sistent arterial hemorrhage must be controlled by haemo- 
static suture. Mere oozing is arrested by the packing. 
The gauze is to be removed in two or three days and the 
wound-cavity kept clean by douching. 

Complete Rupture, (a) Drainage. — When the foetus or 
the larger part of it is still in the uterus it should im- 
mediately be extracted by the natural passages. In ver- 
tex presentation delivery is best eifected by perforation 
in the grasp of the cephalotribe or forceps. The placenta 
must be removed promptly. Should it have escaped into 
the peritoneum it may sometimes be drawn down to the 
uterine wound by the cord and extracted manually. 
Prolapsed intestines must be reposited. Drainage is then 
to be established as follows : A rubber tube one-half inch 
thick is folded, the limbs of the tube tied together, the 



292 ESSENTIALS OF OBSTETRICS. 

bight of the tube perforated in several places and passed 
through the uterine rent and about an inch beyond ; or a 
drain of aseptic wicking or gauze may be substituted for 
the tube. The uterus must be made to contract. The 
drain is removed in two or three days on cessation of 
much discharge. 

(b) Coeliotomy should be done when the foetus is wholly 
in the peritoneal cavity, has long been dead, when there 
has been much hemorrhage into the peritoneum, when 
the cervix is not dilatable, or the site of rupture not fa- 
vorable for drainage. The peritoneum is cleansed by irri- 
gation with the normal salt solution. The uterine lacera- 
tions are closed by deep suture. 

Amputation of the uterus should be resorted to when 
necessary to avert sepsis ; especially is this advisable if 
the lacerations are extensive or the uterus is infected. 

Vaginal hysterectomy may sometimes be substituted 
for abdominal. 

Treatment of Ancemia. — If there is much loss of blood 
the anaemia is to be treated as in other cases, by bandag- 
ing the extremities, raising the foot of the bed, by hypo- 
dermic or intravenous and by rectal injections of the 
saline solution, by the administration of opium, strych- 
nine and by other restorative measures. (See p. 298.) 

THE HEMORRHAGES. 
1. Placenta Prsevia. 
Definition. — The placenta is said to be praevia when its 
site encroaches upon the zone of the uterus which under- 
goes dilatation in the first stage of labor. 

Degrees of Placenta Prcevia. — 1. Partial — partially cov- 
ering the zone of dilatation. 



PATHOLOGY OF LABOR. 293 

2. Complete — wholly covering the zone of dilatation ; 
full central implantation is rare. 

Frequency. — Placenta prsevia is met with in about one 
in one thousand labors. It occurs four to six times more 
frequently in multipara? than in primiparse. 

In 143 cases collected by Chrobak, miscarriage occurred 
in 4 per cent., premature labor in 5 per cent., term deliv- 
ery in 1 per cent. Hemorrhage began as a rule in six 
(lunar) months ; in 2.75 per cent, only three days before 
delivery. The placenta was central in 26 per cent., lat- 
eral in 1 per cent. 

Causes. — Causes of misplaced placenta are conditions 
giving rise to tardy fixation of the ovum, permitting it to 
drop into the lower uterine segment ; e. g., endometritis, 
enlargement of the uterus, relaxation of the uterus, ab- 
normally low position of the tubal orifices. 

The cause of hemorrhage during the labor is the sepa- 
ration of the lower margin of the placenta, which takes 
place as soon as canalization of the cervix begins. Hem- 
orrhage before labor is explained by partial detachment 
of the misplaced placenta occurring from accidental 
causes. 

The source of the bleeding is the uterus, and to a 
limited extent the placenta as well. 

Symptoms. — Usually there are none in the early months. 
The first warning is a sudden outpour of blood of greater 
or less amount. The first hemorrhage is most frequently 
observed in the seventh or eighth month, rarely not till 
the onset of labor. Hemorrhage during pregnancy al- 
ways demands immediate investigation to determine the 
source of the bleeding. This is doubly imperative in the 
later, months. 



294 ESSENTIALS OF OBSTETRICS. 

In distinguishing from other hemorrhages it should be 
remembered that bleeding during labor in placenta prsevia 
is most profuse in the intervals between the pains ; 

That bleeding may proceed from a lesion of the venous 
network of the decidua vera, the situation of the placenta 
being normal; 

That hemorrhage persisting after rupture of the mem- 
branes is unfavorable to the diagnosis of placenta prsevia. 

Physical Signs, (a) Abdominal. — 1. The location of 
the placenta may sometimes be made out by abdominal 
palpation. Beneath the placenta the foetal parts are ob- 
scure to the touch, elsewhere they are more distinctly 
felt. In most instances of anterior implantation the 
convex edge of the placenta can be traced as a resisting 
ring. 

2. Mapping out the round ligaments by abdominal pal- 
pation, if they are found to run over the anterior surface 
of the uterine tumor, it maybe assumed that the placental 
implantation is upon the posterior wall of the uterus ; if 
they run along the lateral margins of the uterus, the pla- 
cental seat is on the anterior wall. When they are not 
found in either of these positions a prsevial insertion is 
to be suspected. 

(b) Vaginal. — Unusual development of the cervix, 
especially when the placenta prsevia is complete ; 

A cushiony mass between the presenting part of the 
fcetus and the examining finger; 

The characteristic stringy feel of the detached surface 
of the placenta on examination through the cervical canal ; 
distinguish from blood-clots which are more friable. 
Bear in mind that the portion of placenta over the cervix 
may be only an adventitious cotyledon. 



PATHOLOGY OF LABOR. 295 

Bogginess of the cervix and lower segment of the 
uterus, commonly mentioned, is not characteristic; 

In marginal placenta prsevia the edge may be felt if 
detached. 

Prognosis. — The maternal mortality in cases that go to 
the later weeks of pregnancy is one-fifth to one-fourth, 
including deaths from the sequelae. Two-thirds of the 
children are lost. 

The maternal mortality results from hemorrhage, 
shock, sepsis, and thrombotic affections ; the foetal from 
asphyxia, the effect of the maternal hemorrhage on its 
blood-supply, prematurity and operative causes. The 
mortality for both mother and child obviously must vary, 
however, with the degree of hemorrhage. Maternal 
deaths from placenta prsevia are extremely rare be- 
fore the seventh month. The danger to life increases 
as gestation advances by reason of the increasing size 
of the blood vessels and the progressive loosening of 
the placental attachment. Post-partum hemorrhage is 
common. 

Hemorrhage begins earlier in partial than in complete 
placenta prsevia since the small portion of free placenta 
in the former slides more readily than does a placenta im- 
planted all about the os. 

It should be remembered that hemorrhage may be pro- 
fuse with partial, or insignificant with complete, placenta 
prsevia. 

Treatment, (a) Before Viability. — Generally the treat- 
ment should be expectant. Partial or complete rest must 
be enjoined according to the amount of bleeding, and a 
general regimen prescribed very similar to that pursued 
for the arrest of threatened abortion or premature labor. 



296 ESSENTIALS OF OBSTETRICS. 

If the hemorrhage is copious, the placenta prsevia com- 
plete, or the foetus dead, the uterus should be emptied. 

(b) After Viability. — Induction of labor is indicated 
immediately the diagnosis is made, simple cases excepted. 

Management of Labor. — The princip al indication in the 
management of labor with placenta prsevia is the control 
of hemorrhage. Hemorrhage controlled, wait, but remain 
with the patient until delivered. 

Nature is equal to the control of the bleeding in rare 
cases of partial placenta prsevia by extra-rapid delivery. 

Rupture of the Membranes and the application of a firm 
abdominal binder may suffice in simple cases of partial 
placenta prsevia. If uterine contractions are efficient or 
can be made so by stimulation the bleeding usually is 
controlled in the lesser degrees of vicious implantation. 
The presenting pole acts as a tampon. 

Forceps. — If the cervix is sufficiently dilated forceps, 
with very moderate traction, may be tried in similar con- 
ditions, if required to hold the head in the lower uterine 
segment as a tampon. 

The vaginal tamponade is especially valuable when there 
is little or no dilatation of the cervix. It is a competent 
measure as the chief reliance in the treatment of placenta 
previa in general. The best material is sterilized gauze 
in strips ; it may be used plain or impregnated with a non- 
toxic antiseptic such as oxide of zinc. To pack securely 
it must be wet. The vagina, if healthy, requires no anti- 
septic cleansing before placing the tamponade. The 
dressing is removed in six or eight hours. It may be re- 
newed if the dilatation is not sufficient for delivery or 
resort may be had at once to bipolar version. 

Water-bags. — A most efficient means of controlling the 



PATHOLOGY OF LABOR. 297 

hemorrhage is the dilating water-bag in the cervix, Barnes', 
McLean's, or the Champetier de Ribes. The latter, how- 
ever, though most efficient mechanically, is difficult to 
render aseptic. 

Podalic version is a measure of the greatest value for 
controlling the hemorrhage. It is especially indicated in 
case of much bleeding with little dilatation and before 
rupture of the membranes. "With one or both feet down 
the foetus serves as a conical cervical plug. Bipolar ver- 
sion has the great advantage that it can be done as soon 
as one or two fingers can be passed through the cervix. 
The edge of the placenta is pushed aside and the fingers 
passed through the membranes. Even after sufficient 
dilatation it is seldom necessary to pass the entire hand 
into the uterus. After version the child may be extracted 
when the dilatation is complete. The delivery must be 
effected very slowly and with extreme care to avoid shock. 
As a rule it is better, if possible, to leave the expulsion to 
nature. 

Manual dilatation and immediate extraction of the child, 
recently advocated by eminent authority, must be re- 
garded as a questionable procedure for general adoption 
and doubly so when the woman is exsanguinated or much 
exhausted. 

Other Methods. — Separation of the placenta from the 
lower uterine segment (Barnes) permits retraction of the 
part thus uncovered. The area of detachment should be 
not less than 11.5 cm., 4J inches, in diameter. 

This procedure is not to be recommended except in 
simple cases of partial placenta prsevia. 

Complete separation and extraction of the placenta are 
applicable in case the child is dead or not yet viable. 
(Simpson.) 



298 ESSENTIALS OF OBSTETRICS. 

Extraction of the child by perforation of the placenta in 
central or nearly central implantation is permissible. 

Precautions. — Avoid too precipitate and violent inter- 
ference, especially if there has been much hemorrhage. It 
is largely responsible for the high death-rate of placenta 
prsevia. 

Guard especially against shock, infection and post- 
partum hemorrhage. Ergot should be given for several 
days after labor. 

Treatment of Acute Anaemia. — Treatment is often re- 
quired after the delivery to combat the effects of excessive 
blood-loss. The principal measures are : Elevation of 
the hips, bandaging the extremities — auto-transfusion — 
continued for a few hours, hot applications to the feet ; 
opium, gr. ij p. r. n., or its equivalent ; hypodermic in- 
jections of whiskey, fluid extract of digitalis, TTLj to TTLv, 
strychnine, gr. J-g- ; trinitrin, gr. -^ to gV repeated p. r. 
n. The injection of the normal salt solution (^ of 1 per 
cent., approximately, gr. iij ad §j) into the rectum, into 
the cellular tissue between the scapulae, into a vein or 
behind the mammary glands between the gland and pec- 
toral fascia is a most valuable measure. A readily im- 
provised apparatus for intra- venous infusion is made with 
a glass funnel, a few feet of rubber tubing and a canula 
of glass or metal. Apparatus and solution should be 
sterilized by boiling, and the latter be filtered. The salt 
solution should be slowly injected at the temperature of 
100° F. Two or three pints may be used. 

The post-mammary injection is simple, safe and 
scarcely inferior in efficiency to intra-venous infusion. 
For this or other subcutaneous injections a coarse aspi- 
rating needle attached to a fountain syringe may be used ; 
all must be sterile. 



PATHOLOGY OF LABOR. 299 

The large bowel is kept filled with the physiological 
saline solution, with plain warm water, or with suitable 
nutrient enemata. 

For the thirst a saline drink — e. g., a weak solution of 
ammonium acetate — is recommended. Liquids by the 
stomach must be given in small quantities and often be- 
ginning with 5j, at intervals of a minute or two. Plain 
hot water, brandy or whiskey and hot water are good re- 
storatives. The use of nutrient fluids may be begun after 
a few hours. 

2. Accidental Hemorrhage. 

This term applies to bleeding resulting from the partial 
or complete separation of a normally seated placenta oc- 
curring in the later months of pregnancy or at the begin- 
ing of labor. 

Varieties, (a) Apparent, in which the blood is dis- 
charged by the vagina. 

(b) Concealed, in which the effused blood collects in the 
uterine cavity. Either of the following conditions may 
obtain : 

1. Placenta detached at the center, the margin adherent; 

2. Placenta detached at one edge, partially lifting the 
membranes beyond the margin ; 

3. Same as in 2, but overlying membranes ruptured 
and blood escaping into the amniotic sac; 

4. Separation of one edge of the placenta and of the 
adjacent membranes, but the lower segment of the uterus 
occluded by the foetal head. 

Causes. — The loose attachment of the placenta, normal 
to the last weeks of pregnancy; 
Violent muscular effort ; 
Violent uterine contractions ; 



300 ESSENTIALS OF OBSTETRICS. 

Short cord ; 

Excessive distention of uterus ; 
External violence, as blows or falls ; 
Disease of decidual ; 
Placental disease; 
Nephritis ; 

Acute infectious diseases. 

Diagnosis. Apparent Variety. — It is necessary to dis- 
tinguish from rupture of the uterus and from placenta 
prsevia. The former occurs later in labor and is attended 
with recession of the presenting part, with diminution of 
the uterine tumor and the development of a new ab- 
dominal tumor. The latter is readily recognized or ex- 
cluded by a physical examination. Bleeding from low 
implantation of the placenta may easily be mistaken for 
accidental hemorrhage. 

Concealed Variety. — The principal signs are : 
Persistent tension of the uterus ; 
A node or boss on the uterine surface at the site 

of the retro-placental blood collection ; 
Atony of the uterus ; 
Uterine tumor boggy ; 
Foetal parts obscured to palpation ; 
Continuous pain in certain cases from distention of 

the perimetrium ; 
Bloody liquor amnii — detected by pushing up the 
presenting part and allowing a portion of the 
liquor amnii to escape ; 
Foetal heart-tones feeble and irregular. 
Signs of internal hemorrhage, viz., collapse, pallor, sur- 
face cold, clammy, especially the extremities, excessive 
perspiration, respiration irregular, sighing, sobbing, yawn- 



PATHOLOGY OF LABOR. 301 

ing, pulse rapid, thready, compressible, thirst, jactitation, 
tinnitus auriura, dyspnoea, nausea, dimness of vision, syn- 
cope. It should be remembered that concealed may co- 
exist with an insignificant apparent hemorrhage. 

Prognosis. Apparent Variety. — In this form the prog- 
nosis is not usually grave for the mother, but frequently is 
fatal to the child. 

Concealed Variety. — For the mothers the mortality is 50 
per cent, from shock due to hyperdistention of the uterus 
and operative causes, from blood-loss before and during 
labor, from post-partum hemorrhage and the sequelae ; the 
foetal death-rate is 90 per cent, or more, chiefly from as- 
phyxia due to interruption of the utero-placental circula- 
tion. Prematurity is sometimes a contributing cause. 

Treatment. — In the apparent variety if the bleeding is 
slight no intervention may be required. Generally in 
either variety the cervix should be dilated manually and 
the membranes be ruptured. Firm compression of the 
uterus is maintained by means of a binder, or by manual 
support applied by a skilled assistant, and ergot is given 
hypodermically. After full dilatation the delivery is 
rapidly completed by forceps or version, or in dead or 
non-viable foetus by embryotomy. Precautions should be 
taken against post-partum hemorrhage. 

Post-partum Hemorrhage. 
Definition. — By post-partum hemorrhage is meant hem- 
orrhage occurring shortly after the birth of the child and 
having its origin at the placental site. The accident can 
seldom happen in well-managed labors. Bleeding from 
laceration of the passages does not come within the mean- 
ing of this term in its technical sense. To distinguish ex- 



302 ESSENTIALS OF OBSTETRICS. 

cessive from the physiological flow it is necessary to re- 
member that normally the blood-loss at the birth of the 
child varies from two or three ounces to a pint. 

Causes. — Causes are imperfect ligation of the uterine 
vessels in consequence of inertia uteri from exhaustion, 
over-distention of the uterus, badly managed third stage, 
excessive use of chloroform, albuminuria, hemophilia, full 
bladder, rectum packed with faeces. The retention of 
blood coagula or of fragments of secundines tends to pre- 
vent full uterine retraction and closure of the vessels. 
Uterine neoplasms may have a like effect. 

Diagnosis. Danger Signals. — A history of hemorrhage 
in previous labors ; pulse over-rapid, above 100 ; imper- 
fect retraction detected by palpation over the abdomen ; 
presence of other recognized causes of hemorrhage, such 
as albuminuria, hemophilia, long-continued chloroform 
narcosis, etc. 

'Signs. — A sudden outpour of blood ; no uterine globe ; 
systemic effects of acute hemorrhage. (See page 300.) 

It must not be forgotten that the absence of external 
bleeding does not, alone, forbid the diagnosis of hemor- 
rhage. Excessive bloody flow with firm uterine contrac- 
tion does not proceed from the uterine cavity ; it comes 
from laceration of the cervix, vagina or vulva. 

Treatment. Prophylaxis. — The preventive treatment 
must be addressed to the uterine retraction. The uterus 
should be watched, with the hand continuously on the 
abdomen, from the birth of the child and for at least a 
half-hour after the placenta is delivered. Friction may 
be used if required to provoke normal contractions. Fluid 
extract of ergot, 5ss, hypodermically, and repeated hourly, 
p. r. n., is a valuable prophylactic. It is especially in- 



PATHOLOGY OF LABOR. 303 

dicated after chloroform anaesthesia and in all conditions 
which predispose to hemorrhage. It is a wise precaution 
to give ergot on birth of the head when there is reason to 
fear post-partnm hemorrhage. It is the abuse, not the 
proper use, of ergot that has brought it into disrepute in 
certain quarters. 

Remedial Measures, (a) Moderate Hemorrhage. — Ma- 
nipulation of the uterus, with one or both hands over the 
abdomen ; conjoined manipulation with one hand over the 
abdomen and two or three fingers of the other hand in the 
posterior vaginal fornix forcibly anteflexing and com- 
pressing the uterus ; fluid extract of ergot, 5ss, subcu- 
taneously ; hot intrauterine douche, two or three gallons 
at a temperature of 120° F. 

(b) Severe Hemorrhage. — Compression and kneading of 
the uterus, with one hand in the cavity and the other on 
the abdomen ; hot intrauterine injections of boiled water 
at a temperature between 120° and 125° F.; hand in the 
cavity of the uterus, raking the walls vigorously with the 
finger tips. The addition of 10 per cent or more of acetic 
acid to the hot intrauterine douche adds materially to the 
styptic effect. 

The Uterine Tamponade. — A most efficient measure for 
the control of severe post-partum hemorrhage is the uter- 
ine tamponade with sterilized gauze in strips about two 
inches wide. It should be reserved, however, as a last re- 
sort. 

Method. — Place the patient in the lithotomy position, 
catch the cervix with a volsella and draw it well down. 
Carry the gauze into the cavity of the uterus with a uter- 
ine dressing forceps over the palmar surface of one hand 
as a guide. Lacking instruments the packing may be 



304 ESSENTIALS OF OBSTETRICS. 

placed with the fingers alone. Remove cautiously within 
twenty-four hours. 

Additional Measures are the following : Application of 
the child to the breast as a reflex excito-motor ; flagella- 
tion to the lower abdomen with a wet towel ; faradism of 
the uterus, one electrode within the uterus and one over 
the abdomen or the upper sacral region, or both electrodes 
over the abdomen, one on either side of the uterus ; curet- 
tage ; swabbing the uterine cavity with tincture of iodine. 

Hemorrhage from a lacerated cervix is best controlled 
by suture. The first stitch should be passed just above 
the angle of the tear. Vaginal hemorrhage should be ar- 
rested by suture. Anaemia is treated as in other cases. 

Secondary Post-partum Hemorrhage. 

Definition. — By secondary post-partum hemorrhage is 
understood hemorrhage from the placental site occurring 
within the post-partum month later than six hours after 
labor. 

Causes. — The usual causes are retention of membranes, 
placental fragments or blood-clots,, congestion of the 
uterus from misplacement or other causes, getting up too 
soon, violent emotion. 

Treatment. — Keep the patient in bed and remove the 
causes if possible ; correct uterine displacements. Hot 
vaginal douches, two or three gallons at a temperature of 
120° F., are effective. These measures failing, curette 
the uterine cavity and pack with iodoform gauze ; remove 
the packing in twelve or twenty-four hours. 

SEPARATION OF THE SYMPHYSIS PUBIS. 

Rarely rupture of the pubic symphysis may occur spon- 
taneously, owing to the excessive relaxation of the joint 



PATHOLOGY OF LABOR. 305 

which sometimes develops in the later months of preg- 
nancy. It is more frequently the result of unskillful use 
of forceps. The vagina and bladder are sometimes lacer- 
ated. Tears of the anterior soft parts may extend into 
the peritoneum. 

Diagnostic Signs. — Mobility of the pubic bones upon 
each other ; a sulcus between the bones ; locomotion im- 
peded on getting up. The mobility of the bones is readily 
made out by forcibly flexing and extending the thighs 
and by rotating one knee outward, patient on the back, or 
by requiring the patient to rock the body from side to 
side while standing. 

Treatment. — Keeping the patient in bed with the use 
of a firm pelvic bandage maintained for four w T eeks if 
begun directly after labor, may generally be trusted to 
bring about union of the bones. Neglected cases may be 
treated by vivifying the joint-surfaces subcutaneously and 
applying the bandage for four weeks, the patient main- 
taining a recumbent position. Suturing the bones with 
silkworm-gut, catgut or silver wire is seldom advisable. 

ECLAMPSIA. 

Definition. — Puerperal eclampsia is synonymous with 
puerperal convulsions. The convulsions are epileptiform 
in character, and are usually associated with albuminuria. 
They occur most frequently toward the close of pregnancy, 
during the labor, or in the first few days of the puer- 
perium. Convulsions in childbed from hysteria, epilepsy 
or cerebral lesions, independent of the toxaemia of preg- 
nancy, are not included under this term. 

Frequency. — The frequency is variously estimated at 
about 1 in 500 cases of advanced gestation. It occurs 
20 



306 ESSENTIALS OF OBSTETRICS. 

in about 1 in 5 of all cases of pregnancy nephritis. 
The disease, however, appears to be more prevalent at 
certain times and in certain localities. Nephritis, which 
is generally associated with eclampsia, is found in 5 per 
cent, of gravid women that go to term. Eclampsia is 
three times more frequent in primiparse than in multipara? 
and ten times more so in multiple than in single preg- 
nancies. 

Etiology. — The primal cause of the convulsions is a 
toxaemia with imperfect elimination by the kidneys and 
other emunctories. The precise nature of the poison is 
not yet known, but it is believed to be complex. Ap- 
parently the immediate cause of the convulsions is spasm 
of the arterioles and consequent ansernia of the brain, in- 
duced by the toxic material. The kidney complica- 
tion may be nothing more than acute insufficiency, it 
may be a degenerative lesion, or acute parenchymatous 
nephritis. Sometimes acute supervenes upon chronic ne- 
phritis. In 368 cases examined post-mortem nephritis 
was present in 46 per cent. ; in 54 per cent, there were 
degenerative processes ; the latter doubtless were in part 
secondary to the eclamptic seizure (Prutz). Reflex irrita- 
tion from the uterus is a potent cooperating factor in the 
eclamptic attack. 

Premonitory Symptoms and Signs : 

Scantiness of urine ; 

GEdenia, especially of the face ; 

Lassitude ; 

Headache, generally frontal, suboccipital rarely ; 

Nausea and other digestive derangements ; 

Contracted pupils ; 

Visual disturbances ; 



PATHOLOGY OF LAB OB. 307 

Epigastric pain ; 

Albuminuria ; 

Deficiency of urea and of other urinary solids ; 

Tube-casts in the urine. 

Differential Diagnosis. — Puerperal eclampsia is gener- 
ally to be distinguished from hysteria and epileptic con- 
vulsions by the uriuary examination and by the history. 

Clinical Phenomena. — The attack is usually ushered 
in by the symptoms already referred to. At the onset of 
the convulsive paroxysm the eyes become fixed, apparently 
upon some distant object. Consciousness is abolished. 
Spasms begin in the facial muscles, then become general. 
The convulsion is at first tonic, then clonic. For a time 
the patient is asphyxiated owing to tonic spasm of the 
respiratory muscles. A few seconds later the breathing 
becomes stertorous. Froth oozes from the mouth and 
nostrils. The tongue is usually bitten during the con- 
vulsive seizure and the frothy discharge blood-stained. 

The duration of the convulsion is usually one or two 
minutes. The interval between the attacks may be a few 
minutes or several hours. 

Coma follows the eclamptic seizure, generally subsiding 
within a half hour. The coma, as a rule, deepens after 
each successive convulsion, owing to increasing oedema of 
the meninges or cerebral congestion. The pulse is usually 
rapid, often reaching 140 or more during the attacks. 
The temnerature in different cases varies from normal or 
subnormal to 105° F. or more. The pyrexia is probably 
of toxic origin. Labor begins generally on the occurrence 
of convulsions, if not already established. 

Prognosis. — The prognosis is the more grave the earlier 
the attack in pregnancy or labor. The danger increases 



308 ESSENTIALS OF OBSTETRICS 

with the number of convulsions. Recovery is exceptional 
after fifteen or twenty seizures and seldom occurs after a 
temperature of 105° F. A small and feeble pulse is a 
bad prognostic. Profound coma, complete suppression 
of urine, and paralysis indicate an unfavorable prognosis. 
Impairment of the mental faculties sometimes follows. 
Psychoses result in about 6 percent, of eclamptic women. 

The toxaemia of pregnancy in women pregnant for the 
first time after forty years of age is almost invariably 
fatal if the pregnancy is allowed to go to the later months. 

Pregnancy in primiparae, the subjects of nephritis be- 
fore conception, is uniformly fatal if not interrupted be- 
fore term. (Tyson.) 

The maternal mortality of eclampsia is from 25 to 35 
per cent, from exhaustion, asphyxia, cerebral hemorrhage, 
oedema of the lungs. The percentage of deaths from eclamp- 
sia may be roughly stated as follows : convulsions begin- 
ning before labor, 39 per cent. ; during labor, 29 per 
cent. ; after labor, 19 per cent. The fcetal death-rate is 
from 50 to 70 per cent., mainly from asphyxia. The 
toxic material is transmitted to the fcetal blood and a cer- 
tain proportion of children die after birth from this cause, 
usually by convulsions. 

Treatment. Prophylactic. — A milk-diet limits the tox- 
aemia. It should be given to the exclusion of all other 
food for a time. Farinaceous food, white meats and fish 
may be allowed to a limited extent as the symptoms im- 
prove. 

Free catharsis by salines and diaphoresis by hot air 
baths, hot packs, and the use of sweet spirit of nitre ren- 
der important service by supplementing the crippled elim- 
ination. 



PATHOLOGY OF LABOR. 309 

Water is essential for diuresis ; it may be given hot 
or half-cold, plain or mildly alkaline; from four to 
eight pints may be taken daily, or a pint of normal salt 
solution may be injected behind each breast every four to 
six hours. Colonic irrigation with hot normal salt solu- 
tion using a double canula is an efficient diuretic meas- 
ure. Fifteen to twenty gallons may be used. 

Hot fomentations and dry cups over the kidneys are 
useful. 

Nitroglycerin in full doses is valuable, not only as a 
diuretic but as a direct anti-eclamptic. 

Fluid extract of veratrum viride (Squibb), Tfliij to 
Ttlvj t. i. d., or enough to hold the pulse below seventy, is 
an efficient prophylactic. 

Chloral, 5j to 5ij daily, or the bromide of sodium in 
similar doses is one of the most reliable agents for sub- 
duing the reflexes. 

Iron is frequently indicated. Bashanr's mixture is a 
suitable preparation. 

Marked ursemic symptoms or scanty urinary secretion 
not promptly relieved by dietetic and medicinal measures 
call for the induction of labor. 

Remedial. — The principal reliance for controlling the 
convulsions is the combined use of chloroform inhalation, 
veratrum viride or nitroglycerin, catharsis, diaphoresis, 
active diuresis by hypodermoclysis, and the prompt evac- 
uation of the uterus. For the veratrum chloral may 
sometimes be substituted. Morphine gr. i to 1J hypo- 
dermically in combination with veratrum may replace 
veratrum alone when the pulse is feeble. 

Chloroform. — Pending the action of other remedies 
place the patient at once under chloroform nearly or quite 



310 ESSENTIALS OF OBSTETRICS. 

to the surgical degree. Chloroform by inhalation is an 
almost certain anti-eclamptic. Its use is always impera- 
tive during operative interference. Yet prolonged chloro- 
form narcosis is dangerous ; one or two hours should 
usually be the limit. 

Veratrum Viride. — Inject subcutaneously fluid extract 
of veratrum viride (Squibb) TTLx to Tfl.xx. If at the end 
of a half hour the pulse is not below 60, inject another 
ten minims. A convulsion is substantially impossible 
while the circulation is sufficiently under the influence of 
veratrum to hold the pulse-rate below 60. The patient 
must be required to maintain the recumbent posture while 
using the drug in large doses. Tumultuous action of the 
heart ensues immediately on rising. Collapse under vera- 
trum is successfully combated by the use of morphine 
hypodermically, or by whiskey administered in similar 
manner or by the bowel. 

Veratrum, by its effect as a vasomotor relaxant, not 
only controls convulsions but it acts as a diuretic and a 
diaphoretic. 

Chloral is best given by the rectum in a teacupful of 
milk. The dose may be 5ss hourly till 5j or 5ij have 
been given. 

Catharsis. — For catharsis, calomel and salines, elaterium 
gr. I or croton oil TTLj to THJj, may be employed. 

Diaphoresis. — The free action of the skin is to be main- 
tained by the same measures as in the prophylactic treat- 
ment. 

Diuresis. — Valuable measures for this purpose are hypo- 
dermoclysis, the injection of a pint of normal salt solution 
behind each breast every 4 hours and enteroclysis, irriga- 
tion of the bowel with a hot normal salt solution every 4 



PATHOLOGY OF LABOR. 311 

hours. Fifteen to twenty gallons may be used in this 
manner, using a double current canula, best a Kemp 
canula. 

Other Measures. — Other anti-eclamptic measures of 
repute are : nitroglycerin, gr. -^ to ^ hypodermically ; 
p. r. n., amyl nitrite, Tltv by inhalation ; the inhalation of 
oxygen ; application of ice to the head and the carotids ; 
in marked cyanosis venesection. 

Prompt Evacuation of the Uterus. — Labor usually sets 
in on the occurrence of eclampsia. Measures are indi- 
cated to accelerate the labor if it has already begun, or to 
induce it if not spontaneously established. Convulsions 
cease in more than 80 per cent, of cases after delivery. 
Recourse may be had to manual dilatation of the cervix 
or to Duhrssen's incision in extreme cases. 

It should be stated that the induction of labor for the 
prevention of eclampsia is opposed by certain obstetric 
authorities. Its wisdom, however, either as a prophy- 
lactic or a curative measure can scarcely be questioned 
when other therapeutic measures have failed. 

Precautions. — A cork or a folded napkin may be held 
between the patient's teeth during the convulsive attacks 
to prevent biting the tongue. If the tongue obstructs 
respiration it should be drawn forward. It is sometimes 
useful to remove the mucus from the throat with a swab 
held in the grasp of forceps. 

Cardiac Supports. — If cardiac supports are called for, 
whiskey and strychnine are to be given p. r. n. Inha- 
lations of oxygen are useful. The subcutaneous injection 
of the normal saline solution acts as a stimulant as well 
as an eliminant. 

Restoratives. — During convalescence the anti-eclamptic 



312 ESSENTIALS OF OBSTETRICS. 

and the eliminant treatment are to be continued for two 
or three days, as required and later iron and general tonics 
are indicated as restoratives. 

DIABETES MELLITUS. 

Sugar is to be found in the urine of women shortly be- 
fore and for a few days after childbirth in about 50 per 
cent, of cases. It results from disturbance of the general 
nutrition. The form is most commonly glucose. Occa- 
sionally the glycosuria of this period is a mere lactosuria, 
due to resorption of milk. 

True diabetes mellitus is a serious complication of 
labor and the puerperal state. It is dangerous to the 
mother and is usually fatal to the child. Fortunately, 
it is rarely encountered in child-bed. 

CARDIAC DISEASE. 

Most valvular heart lesions are aggravated by the extra 
tax put upon the heart in the later months of gestation. 
Not infrequently they are the cause of abortion or of pre- 
mature labor. 

Advanced cardiac disease is a dangerous complication 
of labor. Engorgement of the right heart and oedema of 
the lungs often supervene. The danger is greatest at the 
close of the third stage, when a large volume of blood is 
abruptly thrown on the venous side from the uterine 
sinuses. Statistics show that multiple lesions are attended 
with the greatest mortality. Mitral incompetence or espe- 
cially stenosis of the mitral orifice is almost equally fatal. 
Next in gravity is aortic incompetence. 

Treatment. — In the later weeks of gestation and during 
labor the heart should be actively supported. Tincture 



PATHOLOGY OF LABOR. 313 

of strophantus, ttlv q. v. h., or of digitalis, Ttlx, guarded 
with trinitrin, gr. yi^ t. i. d., should be given for several 
days, and continued during labor. Strychnine, gr. -jL to 
3L t. i. d., is useful. 

Laxatives should be given p. r. n. Resort may be had 
to venesection in extreme venous engorgement ; the in- 
halation of amyl nitrite during the third stage is recom- 
mended ; ether should be used in preference to chloroform 
as the anaesthetic, and that only during the severer pains 
of labor. The heart must be relieved as far as possible 
from the strain of labor by the use of artificial aids for 
delivery. Ergot should be omitted, since a little extra 
blood-loss is conservative. In asystole heart stimulants 
and venesection are indicated. Lactation is contraindi- 
cated. 



CHAPTER VII. 
PATHOLOGY OF THE PUERPERAL STATE. 

PUERPERAL INSANITY. 

The mental disorder may begin during pregnancy or 
the puerperal period. In the puerperium the onset occurs 
most frequently at the end of about two weeks, seldom 
after five or six weeks. The psychical disorder very 
commonly takes the form of melancholia, sometimes of 
mania. 

Frequency. — Puerperal insanity occurs in about 1 in 
400 puerperal women. 

Causes. — Causes most frequently assigned are hereditary 
predisposition, bad mental hygiene, violent emotional dis- 
turbance, eclampsia, anaemia, exhaustion, sepsis. Of these 
the predominating cause is sepsis. Recent investigations 
go to prove that the puerperal psychoses originate most 
frequently in some form of toxaemia, especially in septic 
infection. 

Prognosis. — The prognosis is better in the maniacal than 
in the melancholic form. It is not so good in lacta- 
tional insanity as in cases beginning during pregnancy. 
A marked heredity is unfavorable. 

The mortality does not exceed 8 or 9 per cent. Nearly 
70 per cent, recover their reason. 

Treatment. — If proper nursing can be had home treat- 
ment is, in mild cases at least, better than the asylum. 



PATHOLOGY OF THE PUERPERAL STATE. 315 

Look to the mental and physical hygiene. In the puer- 
peral forms suspend nursing. Iron, pil. Blaud, one or 
two t. i. d., or arsenate of iron, gr. ^ t. i. d., is indicated 
in ansemia. The hypodermic injection of the hydrobro- 
mate of hyoscine, in doses of gr. T i^ to gr. Jg- two or 
three times daily, is a useful sedative in maniacal forms. 
Chloral, the bromides, chloramid or paraldehyd may be 
required as sedatives and hypnotics. Chloral, however, is 
contraindicated in marked anaemia. Morphine, gr. J, is 
sometimes permissible. Intestinal fermentation and septic 
infection are to be treated as in other cases. 

GALACTORRHEA. 

This term applies to excessive secretion of milk which 
persists after weaning. The quantity may reach several 
quarts daily. The quality is thin and watery. The 
disease may affect one or both breasts. It often results 
in serious impairment of the general health. 

Treatment. — Treatment consists in the use of a com- 
pression breast-binder, and restriction of liquids. Potas- 
sium iodide, gr. v t. i. d., may be tried. The topical use 
of oleate of atropia may be of service. Coffee diminishes 
the secretion. The free use of purgatives is essential. 
Tonics and general restorative measures are especially 
indicated. 

MASTITIS. 

Frequency. — Mastitis occurs in 5 to 6 per cent, of nurs- 
ing women. It is met with oftener after first than sub- 
sequent labors. It is commoner in blondes than in bru- 
nettes. 

Causes. — Predisposing causes of mammary infection 
are bad general health, lowering the resisting power ; milk 



316 ESSENTIALS OF OBSTETRICS. 

stasis, injuring the vitality of the epithelium of the lactif- 
erous ducts; lesions of the nipples, opening avenues for 
absorption. 

The exciting cause is sepsis. The pus-producing or- 
ganisms may gain access to the gland through nipple 
lesions, through the milk-ducts, or exceptionally by the 
blood-channels from remote septic foci. Staphylococci 
are sometimes found in the milk of healthy nursing 
women. 

Forms. — (1) Subcutaneous. (2) Glandular, or paren- 
chymatous mastitis; this is in the majority of cases a lym- 
phangitis. (3) Subglandular paramastitis. Two or all 
these forms may coexist. 

Diagnosis. — The subcutaneous form presents the charac- 
ters of ordinary phlegmon ; it is usually single. 

The glandular form is characterized by more pain and 
more constitutional disturbance than the subcutaneous ; it 
is generally ushered in by a chill ; it is often multiple ; the 
gland is indurated. 

The Subglandular Form. — In subglandular suppura- 
tion the temperature is persistently high, the pain is deep- 
seated, the gland is not indurated and it floats on the 
underlying fluid. The diagnosis may be confirmed by 
passing an exploring-needle beneath the gland. 

Treatment. (1) Prophylactic. — In simple milk en- 
gorgement without inflammation, massage is indicated. 
The breast should be stroked gently from the base to- 
ward the apex. Restrict the amount of liquids ingested. 
Hypersecretion may be relieved by saline cathartics, or 
in non-nursing patients by the topical use of oleate of 
atropia. Engorged breasts should be supported firmly 
with a compression binder. A pad of cotton-wool is 



PATHOLOGY OF THE PUERPERAL STATE. 317 

placed under the binder over each breast to distribute the 
pressure evenly. An opening in the center of each pad 
relieves the nipple of injurious pressure. The use of a 
compress as tight as can well be borne is of great value 
both as a prophylactic and a curative measure. The 
Murphy binder, made of a straight piece of muslin with a 
deep notch cut in one side for each arm and a shallow one 
in the center for the neck is recommended. A skilfully 
applied roller bandage is most suitable when but one 
breast requires compression. Tonics, especially quinine, 
are useful. The aseptic management and curative treat- 
ment of nipple lesions are an essential part of the treat- 
ment. 

2. Abortive. — Absolute rest of the gland for one or two 
days, restriction of liquids, saline cathartics, oleate of 
atropia, locally, with care lest the milk secretion be too 
much repressed, quinine, gr. v to x twice daily, are useful 
abortive measures. 

Another plan of abortive treatment consists in occa- 
sional removal of the milk with a breast pump, applica- 
tions of ice, and parenchymatous injections of one-half 
drachm of a 3 per cent, carbolic solution. The injections 
are repeated two or three times at intervals of twelve 
hours. 

3. Treatment of Suppuration. — The pus-cavity should 
be opened early and freely, with antiseptic precautions. 
The incision should radiate from the nipple, the areola 
being avoided. The abscess-cavity is to be thoroughly 
cleansed and disinfected. For this purpose the peroxide 
of hydrogen is a good non-toxic disinfectant. Counter- 
openings may be necessary for satisfactory drainage. 
Leave a drainage-tube in each opening ; apply antiseptic 



318 ESSENTIALS' OF OBSTETRICS. 

dressings and compression to obliterate the cavity. 
Cleanse antiseptically once or twice daily and renew the 
dressing. 

Treatment of Sore Nipples. 
The nipples are to be cleansed after each nursing with 
a saturated aqueous solution of boric acid. They are then 
dried and saturated with fresh cacao butter. In excoria- 
tion the following nipple lotion is sometimes useful : 

]$. — Plumbi nitratis gv. x. 

Glycerini 3ij- 

Aquam ad gj — M. 

A soothing antiseptic dressing, and one that does not 
need to be washed off before nursing is the following : 

R. — Glyceriti amyli ") .- ,_ 

Bismuthi subnitratis J aa 3 SS - 

Cleanse the nipples with the boric acid solution after 
nursing and reapply the bismuth mixture. 

A 2J per cent, aqueous solution of carbolic acid is a 
good antiseptic nipple lotion. 

Should these measures fail, rest the nipple for twenty- 
four or thirty-six hours, or let the child nurse through a 
nipple shield. 

To relieve pain during nursing, apply five minutes be- 
fore a 1 or 2 per cent, solution of cocaine previously 
sterilized by boiling, or better a saturated alcoholic solu- 
tion of orthoform. Wash off immediately before nursing. 

Fissures may be lightly touched once daily with a stick 
of nitrate of silver, first pencilling with the cocaine solu- 
tion. Pencilling with a 1 to 5 per cent, solution of silver 
nitrate is efficacious and has the advantage over the solid 
stick of being practically painless. A protargol solution, 
5j and Sj, may be substituted for the nitrate. Painting 



PATHOLOGY OF THE PUERPERAL STATE. 319 

the affected surface with compound tincture of benzoin 
or with ichthyol several times daily is useful, or the fis- 
sures may be cleansed with a 1 per cent, bichloride of 
mercury solution, and after drying with sterile cheese 
cloth painted with thiol collodion, 10 per cent. The 
opening of the milk ducts must not be closed. A nipple 
shield may be worn till healing has taken place. 

PUERPERAL INFECTION. 

Puerperal infection is a wound infection identical with 
that of surgical practice. Synonyms are puerperal fever, 
puerperal septicaemia, metria. 

Frequency. — In pre-antiseptic times puerperal fever 
was a common affection in child-bed. The mortality from 
this cause in hospitals was from 2 to 6 per cent., and so- 
called epidemics with a death-rate of 10 per cent, or even 
more were of frequent occurrence. To-day, in well-man- 
aged maternities less than a fourth of 1 per cent, of puer- 
peral women die from septic infection. 

Bumm found a morbidity of 20 per cent., assuming 
100.5° F. as the normal limit of temperature. 

In general private practice, without antisepsis, there is 
about 1 per cent, of septic deaths, and a large proportion 
of women who survive infection are seriously, often per- 
manently, crippled in health. From 15 to 20 per cent, 
of women dying during the child-bearing age die of puer- 
peral fever. Under a strict asepsis there are practically no 
deaths from puerperal infection in family practice, and the 
morbidity does not exceed 10 per cent. ; even that is usually 
of a mild type. The disease is observed more frequently 
in primipara than in multipara. 

Etiology. — The cause is the introduction of septic 



320 ESSENTIALS OF OBSTETRICS. 

germs into the wounds of the birth-canal during labor or 
the puerperium. Conditions which impair the resisting 
powers act as complicating causes. The puerperal state 
at its best is one of lowered resistance. 

Bacteriology. — The organisms most constantly concerned 
are the streptococci ; staphylococci are frequently met 
with. The bacterium coli commune, the gonococcus, the 
bacillus of diphtheria and certain other microorganisms 
are occasional factors in the pathogeny. Putrefactive bac- 
teria are generally present. Putrefaction of lochia pro- 
duces a soil favorable for the development of pathogenic 
organisms. The putrefactive bacteria act solely, others 
largely, by the effects of their chemical products, toxins. 

The sources of the infecting organisms are the lochia of 
puerperal fever patients, secretion from suppurating 
wounds, erysipelas, diphtheria, and in certain cases scar- 
let fever or typhoid fever owing to complications involv- 
ing the presence of wound-infection germs, also cadaveric 
and other dead and decomposing animal matter. Gonor- 
rhoea is sometimes the source. Self-infection — auto-infec- 
tion — in the true sense of the term does not exist. The 
term as now used is applied to infection from septic mat- 
ter primarily present in the genital tract. Infection from 
the latter source is probably possible only in diseased 
conditions of the genital mucosa. 

Vehicles of infection are the hands of the obstetrician or 
the nurse, instruments, utensils, cloths, germ-laden dust, 
etc. 

The avenues of absorption are the obstetric wounds of 
the vulva, vagina, the cervix and corpus uteri, and even 
intact surfaces of the genital mucous membrane. Systemic 
infection and that of the uterine adnexa spring most fre- 



PATHOLOGY OF THE PUERPERAL STATE. 321 

quently from the cavity of the uterus, especially from the 
placental site. 

The channels of diffusion are usually the lymphatic. 
Less frequently the veins. 

Special Manifestations are : Endometritis ; salpingitis : 
oophoritis ; metritis ; parametritis ; perimetritis or pelvic 
peritonitis ; diffuse peritonitis ; uterine lymphangitis and 
phlegmonous lymphadenitis — generally accompanied with 
peritonitis ; phlebitis — uterine, peri-uterine, and crural ; 
colpitis; pure septicaemia; acute ptomain-poisoning — putrid 
intoxication ; saprsemia ; pyaemia ; cystitis ; uretero-pyelitis, 
pneumonia, pleurisy, pericarditis, endocarditis, nephritis, 
arthritis, subcutaneous phlegmons, and others. 

Diagnosis. General Symptoms of Infection. — Usually 
the first symptoms appear on the second or third day after 
labor, rarely later than the fourth or fifth, since the ob- 
stetric wounds have by that time begun to granulate, and 
the granulation layer acts as a barrier to the invasion of 
the pyogenic organisms. In the majority of cases the dis- 
ease begins insidiously. The attack is sometimes ushered 
in by a more or less pronounced chill. 

The most conspicuous early symptoms are rapid pulse, 
100 to 140 ; rise of temperature, 102° to 104° F., fetid 
lochia — yet sepsis often occurs without fetor. The bad 
odor is due to the presence of putrefactive bacteria or of 
the colon bacillus, and is often absent at the onset of sepsis 
in the most virulent forms of puerperal infection. Ex- 
clude malarial pyrexia by quinine or better by micro- 
scopic examination of the blood for plasmodia malaria? ; 
exclude also pneumonia, typhoid fever, fecal retention, 
emotional, mammary and other non-septic causes of high 
temperature. 
21 



322 ESSENTIALS OF OBSTETRICS. 

Symptoms of Special Lesions. 

Endometritis. — This is the lesion most constantly pres- 
ent in puerperal sepsis. The uterus is more than nor- 
mally sensitive on palpation over the lower abdomen ; the 
cervix is more patulous than normal for the time; the 
uterine lochia are often foul ; the bloody flow is usually 
prolonged. Generally owing to a greater or less degree 
of accompanying metritis the uterus is somewhat boggy, 
tender on pressure, and involution is retarded. 

Sometimes the septic process is limited to the endome- 
trium, the organisms not penetrating beyond the granula- 
tion-zone. When for any reason that protection fails the 
sepsis becomes widespread and the systemic disturbance 
proportionately greater. Occasionally in profound gen- 
eral sepsis the endometritis may be insignificant owing to 
early migration of the offending organisms into other 
structures. 

Metritis. — This originates in a lymphangitis of the 
uterine walls. It is generally secondary to an endome- 
tritis. Portions of the muscularis may slough — dissecting 
metritis. After-pains are severe and prolonged. The 
uterus is large, soft and boggy and tender to the touch. 

Parametritis and Perimetritis. — There are pain and ten- 
derness at the seat of inflammation, moderate tympanites, 
frequently nausea ; the lochia are scanty ; an exudate is 
found in one or both broad ligaments by abdominal or 
bimanual examination ; the uterus is more or less fixed, 
sometimes displaced ; fluctuation may generally be made 
out at the seat of the exudate if pus forms. Abscess re- 
sults in 20 per cent, of cases. The pus-collection may 
be in the broad ligament, extra-peritoneal, or it may be in- 



PATHOLOGY OF THE PUERPERAL STATE. 323 

tra-peritoneal and encysted, the result of a circumscribed 
peritonitis and agglutination of surrounding structures, or 
of walling off by exudate. 

Diffuse Peritonitis. — The route by which the pyogenic 
organisms reach the peritoneum is almost invariably the 
lymphatics. There are exquisite abdominal pain and 
tenderness in the early stages generally ; later tenderness 
may partially or wholly disappear. Tympanites is usu- 
ally extreme. There is vomiting of greenish fluid, diar- 
rhoea, and finally collapse. The termination is almost 
surely fatal within a week. 

Phlegmasia Alba Dolens, Milk-leg is primarily a lym- 
phangitis. Its origin is parametritis, the inflammatory 
process extending along the courses of the great blood 
vessels of the thigh. Phlebitis results secondarily. 

The period of invasion varies from two to three or 
four weeks after delivery. The attack is sometimes 
ushered in with a chill, and is always attended with 
pain and swelling in the affected limb. The pain is 
first felt in the groin, and usually extends throughout 
the length of the thigh and leg within a few hours. 
The limb becomes swollen, tense, hard, white, glisten- 
ing. The affected veins may sometimes be felt on pal- 
pation, as hard, irregular cords. They are frequently 
nodular, owing to the formation of thrombi. The fever is 
at first of a remittent, then an intermittent type. Res- 
olution generally begins after about two weeks. The 
duration of the disease may be many weeks ; abscess- 
formation or gangrene sometimes supervenes. There re- 
mains more or less oedema on standing or walking with 
impairment of muscular power. In a certain proportion 
of cases the disability may last for months or indefinitely. 



324 ESSENTIALS OF OBSTETRICS. 

A possible termination is sudden death by pulmonary 
embolism from the detachment of a fragment of blood -clot. 
Recurring chills are a signal of metastatic affections. 
The disease may extend from one limb to the other. 

Colpitis. — The usual evidences of vaginal inflammation, 
catarrhal, phlegmonous, ulcerative or diphtheritic are pres- 
ent ; in ulcerative vaginitis the labia are often oedematous. 
In the phlegmonous form abscess may result. Membra- 
nous exudates are very rarely due to a true diphtheria, 
usually to infection with pyogenic organisms. 

Pure Septicaemia is characterized by fever with absence 
of appreciable organic lesions ; the countenance is sallow, 
sunken, anxious. Occasionally there is delirium or 
coma ; diarrhoea and vomiting of dark grumous ejecta are 
frequently observed. It runs a rapid course, often termi- 
nating within two or three days. 

Pyaemia. — Pyaemia originates most frequently in infec- 
tion of the mouths of veins at the placental site. The 
phlebitic process may be limited or diffuse. By the break- 
ing down of infected thrombi, septic emboli and meta- 
static abscesses in various parts of the body may result. 
Septic pneumonia is a common complication. 

Pyaemia is distinguished by irregularly recurring chills, 
marked irregularity of the temperature, and by metastatic 
development of purulent foci. The duration may be many 
weeks. Often it progresses to a rapidly fatal termination. 

Cystitis is attended with vesical tenesmus and increased 
frequency of urination. In the acute stage the tenesmus 
is almost constant, and is not relieved by emptying the 
bladder. Pain is sometimes excessive, and there is usu- 
ally some elevation of temperature. The urine is cloudy 
and of feebly acid reaction ; sometimes it is fetid. 



PATHOLOGY OF THE PUERPERAL STATE. 325 

Uretero-pyelitis. — In uretero-pyelitis there is frequent 
desire to urinate, with pain and tenderness along the in- 
flamed tract. Pressure on the ureter through the vagina 
by conjoined manipulation elicits pain and desire to uri- 
nate. The urine is acid and contains pus and blood. 
The temperature is very high in the acute stage. 

In most cases of puerperal infection several of the 
lesions above described coexist. 

Prognosis. — As a rule the earlier the attack the more 
unfavorable the prognosis. It is gravest in acute putrid 
intoxication, diffuse purulent peritonitis, pysemia. Gener- 
ally the prognosis is best when the septic process is dis- 
tinctly localized. 

Treatment. Prophylactic. — To prevent infection en- 
force a rigorous asepsis of the hands, instruments, uten- 
sils, and of everything that comes in contact with the 
genitals during labor and the puerperium. Cleanse an- 
tiseptically the external genitals, lower abdomen and 
inner surfaces of the thighs before internal examinations. 
Disinfect the vagina and cervix before and during labor 
for cause. Examine by the vagina during labor as sel- 
dom as possible. In many cases vaginal examinations 
may, when, for any reason, more than ordinary care is 
required, be omitted altogether. Prevent all preventable 
injuries of the passages. Under modern methods of 
prophylaxis there should be practically no mortality from 
puerperal infection in private practice. 

Remedial General Treatment of Infection. — The treatment 
may be summed up in a few words : Dislodge the enemy, when 
possible, and reinforce the resisting powers of the patient. 

Catharsis. — On the first rise of temperature give calo- 
mel, gr. v to gr. x, and follow with a saline, Epsom salt. 



326 ESSENTIALS OF OBSTETRICS. 

Repeat the saline, as required, to procure three or four 
watery movements daily, if the strength of the patient 
permits. Hypercatharsis applies especially to the first 
few days of the fever, and should be continued only so 
long as the temperature and other symptoms improve 
under it. 

Spontaneous diarrhoea is generally conservative, and 
should not be checked unless excessive. Should it be 
necessary, the subnitrate of bismuth, gr. x q. 2 to 4 h., 
may be given. A pelvic examination should be made to 
determine, if possible, the seat of infection. 

Vaginal Disinfection. — A careful digital and speculum 
examination to locate the primary focus of infection is a 
necessary preliminary to treatment. Vagina alone in- 
volved, douche with a 2 to 3 per cent, solution of hydro- 
gen peroxide, a 1 in 10 to 15 dilution of Labarraque's 
solution or 2 per cent, carbolic solution. If the tempera- 
ture falls, repeat the douche as soon as it rises again. 
Ulcers and necrotic or pseudo-diphtheritic patches should 
be touched once or twice daily with tincture of iodine, a 
50 per cent, chloride of zinc solution, or with carbolic 
acid. Before any interference within the passages as 
rigorous an antiseptic preparation is required as for a 
major surgical operation. 

Intrauterine Douching. — Intrauterine measures are 
indicated only when the seat of infection has been found 
to be the uterus. The douche should be given only by the 
physician. Patient should be on a table and the asepsis 
should be as elaborate as for a capital operation. Irrigant 
may be warm iodine water, of port wine color, per- 
oxide of hydrogen or normal salt solution. Quantity 
should be two or three gallons. The douche is best given 



PATHOLOGY OF THE PUERPERAL STATE. 327 

with a fountain syringe armed with a glass irrigating tube 
with openings only at the end. It is a useful measure if 
the temperature falls after it. It may be repeated as 
soon as the temperature rises again. 

Curetting. — Curetting is indicated in the presence of 
gross necrotic material. It should be omitted when the 
inner surface of the uterus feels smooth to the examining 
fingers. 

Support the patient with tonics, stimulants and forced 
feeding. Give strychnine, gr. ^L to gr. -^, hypodermic- 
ally every four hours, and brandy to the extent of a pint 
or quart daily ; instead of brandy, whiskey or an equiva- 
lent of wine may be preferred. To realize the full bene- 
fit of the alcohol it should be pushed to the point of in- 
toxication. The subcutaneous injection of a pint to a 
quart of the normal salt solution two or three times daily 
is sometimes of great service as a stimulant and eliminant. 

Antipyretics. — Reduce the temperature by cold spong- 
ing, cold packs, or the use of a cold coil. 

The coal-tar antipyretics serve only to mask the symp- 
toms and are depressing and otherwise injurious. Quinine 
is useless in purely septic fever except in small doses, gr. 
ij or iij t. i. d., as a tonic. Even for the latter purpose 
it is inferior to strychnine. 

Narcotics. — An occasional opiate in small doses, mor- 
phine, gr. I, or codeine, gr. J, may rarely be required in 
case of extreme nervous excitement or sleeplessness, but 
should be withheld if possible. 

Treatment of Peritonitis. — Saline cathartics with large 
stimulating enemata, to secure several copious evacuations 
daily are often of service. Moderate doses of opium will 
rarely be needed for control of pain and restlessness. 



328 ESSENTIALS OF OBSTETRICS. 

Dietetic supports, tonics and stimulants are the chief reli- 
ance in systemic infection. In localized purulent perito- 
nitis open the abdomen, cleanse and drain the pus-cavity. 
The drainage should be established through a posterior 
vaginal incision if possible, and the suprapubic incision 
closed. In diffuse peritonitis abdominal section is rarely 
if ever successful. Gauze drainage of the peritoneum 
through the posterior vaginal fornix might be of service 
at the beginning of a peritonitis. 

Treatment of Parametritis. — Hot vaginal douches, 
several gallons at a temperature of 110° to 120° F., may 
be given two or three times daily. Local antiseptic and 
general tonic measures are indicated as in other septic 
conditions. If abscess forms evacuate early and drain by 
the vagina or abdomen. Operation by the vagina is 
generally safest and it effects the best drainage. This 
route should be chosen except when the pus-cavity cannot 
safely be reached from below. In the latter event the in- 
cision should be made just above Poupart's ligament and 
parallel with it. 

Treatment of Phlegmasia Alba Dolens.— The limb should 
be kept at rest in a horizontal position. Pain may be sub- 
dued by the local application of oleate of morphia. After 
the application the limb is enveloped with a single thick- 
ness of muslin wrung out of hot water, and this covered 
with oiled silk. Ichthyol and glycerine, 1:4, applied 
twice daily over the entire limb frequently yields brilliant 
results. 

Avoid massage during the active stage of the disease ; 
it may cause embolism. Should abscesses form they 
should be treated by early and free incision, followed with 
thorough cleansing and drainage. The patient may leave 



PATHOLOGY OF THE PUERPERAL STATE. 329 

the bed when the swelling subsides and the fever has 
long since ceased. From that time the affected limb 
should be supported by means of a flannel bandage or an 
elastic stocking. The support should be continued so 
long as much swelling occurs on standing or walking. 

Treatment of Pyaemia. — The general treatment is es- 
sentially the same as in septicaemia. Metastatic pus-foci 
should be opened and drained if accessible. 

Treatment of Cystitis. — A mildly alkaline water should 
be drunk freely as a diluent. The bowels must be kept 
freely open, and the diet should be non-stimulating. Sweet 
spirit of nitre, four to six times daily, helps to relieve 
pain. When the acute stage has passed oil of sandalwood 
in doses of 10 to 20 drops from three to six times daily 
is most useful. 

Treatment of Uretero -pyelitis. — Water is to be used 
freely by the stomach or by high rectal injections to flush 
the septic tract by increased secretion of urine. Salol in 
doses of five grains every three hours is useful as an anti- 
septic. Here, as in cystitis, the oil of sandalwood is 
especially valuable. The cystitis must be treated. 

SUDDEN DEATH IN CHILD-BED. 

Among the principal causes of sudden death in child- 
bed those most frequently encountered are shock, syncope, 
apoplexy, advanced cardiac disease, acute pulmonary 
oedema, pulmonary embolism and thrombosis. The latter 
two are the most frequent. Phlebitis, varicose veins, pro- 
longed labor, anaemia, hemorrhage, sepsis, cancer, syphilis, 
predispose to embolism and thrombosis. 



CHAPTER VIII. 

OBSTETEIC SURGERY. 

INDUCTION OF PREMATURE LABOR. 

Indications are certain cases of narrow pelvis, in which 
the delivery of a living and viable child is thus possible, 
flattening to between 7 and 9 cm., 2J to 2J inches, or 
equivalent contraction of other forms ; foetal death ; ha- 
bitual death of the foetus in the last month of gestation 
from other causes than syphilis ; nephritis of pregnancy, 
drug and dietetic measures failing ; dangerous cases of 
placenta prsevia after the period of viability, and acci- 
dental hemorrhage ; certain cases of hydramnios, with 
danger to mother or child. 

1 . Pelvic Contraction. — Here the most difficult problem 
is to fix the proper time for interference. Operating too 
soon, the interests of the child, too late, those of the 
mother, are imperiled. The most reliable data for decid- 
ing the question are afforded by careful measurements of 
the pelvis and of the child, especially the foetal head. 
Crowd the head into the pelvic brim with one hand over 
the abdomen while the other is passed internally to learn 
how far and with how much freedom the head descends 
under repeated examinations at intervals of one or two 
weeks. The labor should be brought on as soon as the 
head is found to enter the pelvis with difficulty. 

The operation is seldom to be chosen in preference to 



OBSTETRIC SURGERY. 331 

its alternatives in pelvic contraction. While its maternal 
death rate is nearly nil the foetal mortality is about 33 
per cent. 

2. Habitual Death of the Foetus. — Operate a week or 
two before the usual period of foetal death. The strength 
and frequency of the foetal heart and the vigor of the 
foetal movements must be watched closely as the fatal 
period approaches. 

3. Nephritis. — The pregnancy should be terminated on 
the appearance of grave symptoms, especially if the foetus 
has reached the full period of viability and medical and 
dietetic treatment have failed. 

4. Hemorrhage. — In placenta prgevia and in accidental 
hemorrhage, after the period of viability, it should be the 
rule to induce labor as soon as the diagnosis is established. 

5. Hydramnios. — Here interference is called for when 
the life of mother or child would be jeopardized by longer 
continuance of the pregnancy. 

Methods, (a) Catheterization of the Uterus. First Step. 
— Separation of the membranes from the lower uterine 
segment by means of a uterine sound or with the finger. 
The operation must be aseptic. 

Detachment of the membranes with the sound may be 
done with the woman in either the left lateral or dorsal 
recumbent position. For the use of the hand the dorsal 
position is best. 

Second Step. — Insertion of one or more English bougies 
between the membranes and the uterus. (Krause.) 

No anaesthetic is required. Usually the bougie is most 
readily passed with the aid of the Sims position, the 
cervix being drawn forward and held with a volsella. 
The bougie is sterilized by boiling or steaming, the proxi- 



332 ESSENTIALS OF OBSTETRICS. 

mal end is cut off and a stylet inserted. Great care must 
be used to avoid rupturing the membranes. The instru- 
ment is then pushed up gently and in the direction in 
which it passes most easily. After it has entered between 
the membranes and the uterine wall the stylet is drawn 
down about one inch. The flexible tip of the bougie finds 
its way readily with little risk of perforating the mem- 
branes. The bougie fully in place the stylet is withdrawn. 
A second bougie may be inserted if it can be pushed into 
place without too much difficulty. Bleeding is probable 
evidence that the instrument has passed behind the pla- 
centa. It is then best to withdraw it and pass it in 
another direction. A light tampon of gauze may be 
packed in the vagina, but it is not required to support 
the bougie. The instrument is left to be expelled with 
the child. Labor is usually established within twenty- 
four hours. This method is not suited to cases in which 
immediate delivery is called for. 

(6) Tamponade of the cervical canal and the vagina 
with plain or borated gauze. The gauze is applied in 
long strips, with the patient in the Sims position, and the 
perineum well retracted with a Sims speculum. The 
tamponade must be as firm as it can be made, and must 
completely fill the vagina and be held in place by means 
of a T-bandage. The cervix and vagina if required should 
be cleansed before packing. The gauze tampon is renewed 
daily till labor is established, the vagina and the cervical 
canal being douched with sterile water or salt solution be- 
fore repacking. The method acts slowly, and is therefore 
unsuitable when prompt delivery is demanded. It is 
especially adapted to cases of hemorrhage. 

(c) Manual Dilatation of the Cervix. — The woman is 



OBSTETRIC SURGERY. 333 

placed in the lithotomy position under an anaesthetic. 
The vulvar hair is clipped short and the external genitals 
are disinfected. The vagina and cervix if healthy re- 
quire no disinfection. If diseased the vagina is gently 
scrubbed with soap and water, using sponge compresses 
held in the grasp of straight forceps. Finally, it is 
douched for five minutes with one of the mercurial solu- 
tions, using gentle friction with sponge compresses fre- 
quently renewed. The cervical canal is cleansed with 
equal care. 

The operator then lubricates his hand well with aseptic 
glycerin. Coning the fingers the hand is introduced into 
the vagina. One finger is passed through the cervix. 
After a time the cervix relaxes till a second finger can be 
passed, then one finger after another until the whole hand 
is introduced. The first is then slowly and cautiously 
closed in the grasp of the cervix. By this time the dila- 
tation is sufficient for the passage of the head, and at the 
same time active uterine contractions have been established. 

The dilatation must be done with the least possible 
muscular effort, to prevent cramping of the hand. To 
prevent laceration of the cervix extreme care must be 
used, taking plenty of time for each step. The danger of 
tearing is greatest in the latter part of the dilatation. 
The uterus is steadied by counter-pressure over the fundus 
lest by pushing the uterus upward the vagina be exposed 
to too great strain. 

Should the indications warrant immediate extraction may 
be undertaken by version of forceps. Delivery is thus 
possible within fifteen minutes to two or three hours, ac- 
cording to the rigidity of the cervix and the difficulty of 
extraction. 



334 



ESSENTIALS OF OBSTETRICS. 



When the cervical canal is too small to admit the 
finger easily the dilatation may be commenced with a 
branched steel dilator. Or, if time permits, a cervical 
and vaginal tampon may be placed and left for twenty- 
four hours. By the end of that time the cervical canal 
will be found sufficiently expanded to receive the finger. 

Edgar dilates by hooking one or two fingers of one 
hand in the cervix anteriorly and one or two fingers of 
the other hand posteriorly and pulling in opposite di- 
rections. 

The method of artificial delivery by rapid dilatation of 
the cervix is a dangerous one except at the hands of a 
trained and skillful operator, and is to be reserved for 
emergencies only. No important injury need result from 
lacerations of the cervix if they are properly sutured at 
the close of labor, but without the greatest caution the 
tear may extend into the lower uterine segment and even 
into the peritoneum. Dilatation of the cervix by means 



Fig. 62. 




Barnes' dilating •water- 



OBSTETRIC SURGERY. 
Fig. 63. 



335 




Ghana petier de Ribes 



of water-bags is tedious, but is generally safer, and is to 
be preferred when the indication for delivery is not too 
urgent. (Figs. 62, 63, 64.) 

(e) Diihrssen's Incisions. — In this operation four longi- 
tudinal incisions are made in the cervix at equal intervals. 
They are best located a little to one side of the anterior, 
the posterior, and right and left aspects of the cervix re- 
spectively. They should extend to the vaginal junction. 
With the patient in the dorsal position and the cervix 
drawn down with a volsella, and using two fingers of the 



336 ESSENTIALS OF OBSTETRICS. 

left hand as a guide, one within and the other without the 
cervix, the cuts are made with a strong straight scissors. 
The method is applicable only after dilatation has pro- 
gressed far enough to obliterate the internal os. The pre- 
liminary dilatation may be accomplished by manual or in- 
strumental intervention, if it has not already taken place 
spontaneously. The operation, when done as described, 
aifords ample space for extraction of the child. The inci- 
sions should be closed, after delivery, by immediate suture. 

Care of the Child. — Generally in case of premature 
children the use of an incubator will be required. In hos- 
pital practice an Auvard's, Crede's, Rotch's or Marx's ap- 
paratus should be provided. For use in private practice 
an improvised incubator of wood or metal may readily be 
constructed. It should have a removable cover and a false 
bottom. The child is placed in the upper chamber and 
hot bottles, or a metal water tank heated by an alcohol 
lamp in the lower. Air admitted to the lower chamber 
flows into the upper through several half-inch perforations 
at one end of the false bottom, escaping by similar per- 
forations at the opposite end of the top or cover. A ther- 
mometer in the upper chamber should register constantly 
about 90° F. A glass window in the top of the incuba- 
tor permits observation of both child and thermometer. 
The usual period of incubation is from one to three 
months. Meantime the child is removed from the warm 
chamber only for nursing, bathing, and changing of 
clothing. 

Recourse must be had to gavage, feeding through a soft 
stomach-tube, when the child is unable to nurse the breast 
or bottle or to be fed from a spoon. Better than the stom- 
ach tube is feeding through the nares by means of a nar- 



OBSTETRIC SURGERY. 337 

row-pointed spoon. By incubation and gavage 20 per cent, 
of children born at the sixth month may be saved. The 
viability is correspondingly greater in more advanced 
stages of gestation. 

INDUCTION OF ABORTION. 
Indications. — 1. Pregnancy nephritis with grave symp- 
toms not yielding to other measures ; chronic nephritis. 
In chronic nephritis the termination of the pregnancy is 
demanded because development to viability and the birth 
of a living child are exceedingly rare and the child if born 
alive is puny and feeble. The mother's life, too, is seri- 
ously jeopardized by the continuance of the pregnancy. 
Even if she survives the pregnancy and the labor grave 
injury will have been done to the crippled kidneys. 

2. Uncontrollable Vomiting of Pregnancy. — Medicinal 
and dietetic measures failing, the uterus should be emptied 
before the occurrence of grave symptoms. 

3. Extensive Vesicular Degeneration of the Chorion. — 
The diagnosis established and no evidence of foetal 
life being discovered, the uterus should be evacuated 
promptly. 

4. Irreducible Retroversion of the Gravid Uterus. — The 
retroverted gravid uterus is very rarely irreducible, 
before the third month. Before resorting to abortion, 
the usual measures for reduction, with the woman in the 
Sims or the genu-pectoral position, should have had a 
fair trial. 

5. Absolute Contraction of the Pelvis. — The termination 
of the pregnancy in the early months is demanded, on 
election of the mother, especially in conditions unfavor- 
able for coeliotomy. This applies to contraction of the 

22 



338 ESSENTIALS OF OBSTETRICS. 

soft parts and to obstructing tumors as well as to distor- 
tion of the bony pelvis. 

6. Pernicious Ancemia. 

7. Chorea. — Chorea as a complication of pregnancy is 
generally an intractable disease and sometimes dangerous 
to life. 

8. Death of the ovum calls for evacuation of the uterus 
immediately the diagnosis of death of the foetus can be 
established positively. 

9. Chronic Heart Disease. — In advanced cardiac disease 
the heart suffers impairment owing to the extra tax to 
which it is subjected in the later months of pregnancy, 
and the life of the patient is seriously jeopardized at 
labor. 

Methods. 1. Detachment of the Ovum and Tamponade 
of the Cervix. — Abortion may be induced by partially de- 
taching the ovum with a uterine sound aseptically, or by 
the use of the cervical and vaginal tamponade with plain 
or boric acid gauze as already detailed under induction of 
premature labor, or these procedures may be employed 
conjointly. The tampon is renewed after twenty-four 
hours. The strictest asepsis must be observed. 

2. Immediate evacuation of the uterus with the curette 
is the method preferred by the writer. The patient 
is placed under an anaesthetic in the lithotomy or in 
the Sims position. The external genitals are scrubbed 
for five minutes by the nurse with soap and hot water. 
The operator then scrubs the vulva and immediate sur- 
roundings with soap and hot water. For cleansing the 
skin a soft aseptic brush or the hand may be used. The 
vagina if infected is cleansed and douched with one of the 
mercurial solutions for five minutes and the external sur- 



OBSTETRIC SURGERY. 339 

faces flashed with the same, using friction with fresh com- 
presses. The cervix is exposed by the aid of a Sims spec- 
ulum, is drawn down with a volsella, and its canal is also 
cleansed and disinfected. The cervix is now dilated suffi- 
ciently to easily admit the largest curette to be used, care 
being taken to avoid lacerating the tissues. 

When gestation has not advanced beyond the second 
month, the ovum may be broken up and the larger por- 
tion of it brought away with a Keith forceps ; the remaining 
fragments and the decidua are then removed with the 
curette. 

The Keith or similar straight forceps will be found use- 
ful for the removal of debris that is not brought away by 
the curette or by douching. The curetting is best done 
with a sharp curette and should be continued till the 
decidua has been removed. 

The operator knows by the peculiar grating sound and 
by the harsh feel when the instrument has reached the 
uterine wall. The ovum or the decidua has a smooth or 
spongy feel, and gives out no sound as the curette is drawn 
over it. The sharp curette does its work with much lighter 
pressure than the dull instrument and, therefore, with less 
injury by bruising ; with proper care it will not cut too 
deeply. 

The uterine cavity is finally douched thoroughly 
with a T 7 o- per cent, salt solution or with plain sterilized 
water. A half drachm of fluid extract of ergot may be 
given hypodermically as a precaution against hemorrhage. 
In aseptic conditions no pack is required and no vaginal 
dressing. 

When the contents of the uterus have become necrotic 
the cavity should be irrigated with the mercurial or other 



340 ESSENTIALS OF OBSTETRICS. 

equally active antiseptic solution. In such cases the 
uterus may be packed lightly with gauze after curetting. 
The gauze usually becomes foul and must be removed in 
twenty-four hours. Repacking is seldom advisable. 

When the gestation has advanced much beyond the 
second month the dilatation may be begun with the steel 
dilator and completed with the fingers. The foetus is 
brought down and extracted by seizing the feet and the 
secundines delivered by conjoined manipulation. For 
manual evacuation the patient should be in the dorsal 
recumbent position. 

For the protection of the physician it is a rule of prac- 
tice never to induce abortion except with the approval of 
competent counsel. 

REMOVAL OF AN ABNORMALLY ADHERENT 
PLACENTA. 

Note. — The existence of abnormal adhesion of the pla- 
centa may be assumed, as a rule, when the after-birth can- 
not be delivered entire by ordinary external and internal 
manual methods within two hours after the birth of the 
child. Mere retention, however, by partial closure of the 
retraction-ring must not be mistaken for adhesion. 

Etiology. — The etiology is not definitely understood. 
The cause of pathological adhesions of the placenta resides 
probably in a diseased condition of the endometrium ante- 
dating the pregnancy and resulting in deciduitis and pla- 
centitis. It should be remembered that an abnormally 
retained placenta is, as a rule, at least partially adherent 
and that the adhesion is very seldom pathological except 
in persistence. Unnaturally firm adhesion of the kind 



OBSTETRIC SURGERY. 341 

which is attributable to inflammatory causes is extremely 
rare. 

Treatment. — The treatment is separation and extraction 
of the placenta with the hand in the uterus. The patient 
should be placed in lithotomy position upon a suitable 
table. A rigid asepsis must be observed. The separation 
is begun at the portion already detached. Care must be 
taken that no fragments remain. After evacuating the 
uterus give a hot intrauterine douche of a 2 per cent, 
solution of creolin or of hot saline solution. Inject 30 
minims of fluid ergot hypodermically. 

The removal of an adherent placenta with the naked 
hand even though carefully disinfected is always attended 
with serious risk of infection. A safeguard against in- 
fection in intrauterine manipulation is the boiled rubber 
glove^with gauntlet. 

FORCEPS. 
The Instrument. — The obstetric forceps consists of two 
crossed arms locking at the point of intersection. Each 
arm has four parts, handle, shank, lock and blade. The 
blades are shaped to grasp the foetal head as with a pair ot 
hands. They are also curved in conformity with the direc- 
tion of the birth-canal. For lightness as well as for wider 
distribution of the pressure the blades are fenestrated. 
When the instrument is locked the handles fall nearly 
together, affording a convenient grasp for the operator's 
hand in applying traction. A forceps for general use 
should be about 38 cm., 15 inches, long, and should have 
a moderate pelvic curve and an elliptical cranial curve, 17 
to 18 cm., about 7 inches, long, and 7.5 cm., 3 inches, in 
width externally at the widest part. The space between 



342 ESSENTIALS OF OBSTETRICS. 

the tips of the blades when the instrument is closed should 
be 1.3 cm., about J inch. To admit of sterilizing by 
heat it is best made wholly of metal. (Fig. 65.) 



Fig. 




The author's forceps. 

It should be thoroughly cleansed with soap, hot water, 
and a brush after using ; should always be sterilized, best 
by boiling in the soda solution, immediately before using. 
It should be kept free from rust and well polished and the 
nickel plating must occasionally be renewed. 

Mechanical Action. — The essential function of the 
forceps is traction. 

Its use as a lever, by means of a pendulum motion during 
extraction, is a mechanical gain, but is liable to injure the 
maternal soft parts. 

The use of forceps as a rotator is considered under 
treatment of occipito-posterior positions of the vertex 
and of face presentation. 

Compression of the head with forceps is attended with 
danger to the child and but little mechanical advantage 
for extraction. In most seizures compression of one is 
compensated by elongation of another transverse diameter. 
More may be gained by slow delivery, permitting time 
for moulding of the head under the pressure of the pelvic 
walls. The pressure of the blades should be kept at a 
minimum, and if possible should be light enough to leave 
no marks upon the child. 



OBSTETRIC SURGERY. 343 

Indications for Forceps. 1. Forces at Fault. — Ce- 
phalic presentation in which the natural powers are clearly 
inadequate. 

Generally — not always — when the head has remained 
stationary for a half hour after two hours in the second 
stage. 

2. Passages at Fault. — Flattening, not below three and 
one-half inches, in the true conjugate, or equivalent ob- 
struction. 

Partial obstruction in the soft parts. 

As a rule, the forceps is permissible only after the head 
has engaged or can be made to engage. In most instances 
symphysiotomy or Cesarean section is better than a very 
difficult forceps extraction. 

3. Child at Fault. — Among the indications for forceps 
presented by the foetus are : 

Arrested occipito-posterior positions. 

Arrested face presentation in anterior position. 

Moderate hydrocephalus. 

After-coming head. 

Impacted breech. 

Foetal pulse above 160 or below 100. 

In impacted malpositions of the head and in irreducible 
face or brow presentation symphysiotomy may be con- 
sidered. 

Complicated Labor. — Forceps is often required in emer- 
gencies arising from other causes than faulty mechanism 
and in which immediate delivery is indicated in the interest 
of mother or child. This indication may be present before 
the head engages. Under this head may be mentioned 
certain cases of accidental hemorrhage, prolapsus funis, 
rupture of the uterus, and of eclampsia, for rapid de- 



344 ESSENTIALS OF OBSTETRICS. 

livery, or of placenta prsevia to hold the head down as a 
tampon. 

Contraindications are : Head incapable of engagement, 
pelvic contraction below 3J inches, c.v., head hydrocephalic 
or macerated or perforated, cervix not fully dilated and un- 
dilatable. 

Dangers of the Forceps Operation, (a) To the 
Mother. — Possible injuries, especially in unskillful use of 
forceps are : In the low operation, vaginal lacerations 
and injuries to the pelvic floor ; in the high operation 
contusion and laceration of the cervix, or even the body 
of the uterus, shock and sepsis. Separation of the pelvic 
joints has resulted from the use of excessive and mis- 
directed force. 

(b) To the Child. — Brain injuries and especially rupture 
of cerebral vessels by compression are not infrequent. 
Permanent mental and physical infirmities and even 
death sometimes result from difficult forceps delivery. 
Temporary paralysis of the facial nerves frequently oc- 
curs. Duchenne's paralysis may result from the effect of 
stretching the nerve-trunks that enter into the brachial 
plexus. An uncleanly and unskilled forceps delivery is 
a dangerous operation for both patients, especially in 
high applications. 

Application of Forceps. Preparatory Measures. — The 
patient is usually placed on the bed, or better on a table 
in the dorsal recumbent posture — the American obstetric 
position. 

In difficult high forceps operations the Walcher posi- 
tion may be utilized as follows : The patient lies flat on 
her back on the table with the hips overreaching the 
edge and with the thighs hanging in extreme exten- 



( 



OBSTETRIC SURGERY. 345 

sion. In this position, owing to nutation of the sacrum, 
there is a perceptible lengthening of the antero-posterior 
diameters of the pelvis at the brim. On the other hand, 
at the outlet of the bony pelvis the lithotomy position 
offers the greatest advantage, tilting the lower end of the 
sacrum backward. 

The woman should be anaesthetized and the hips 
brought close to the edge of the bed or table. The blad- 
der and rectum must be empty. Examine the foetal 
heart before and occasionally during the operation. The 
abdomen, the thighs, and the external genitals must be 
cleansed and disinfected as for a major surgical operation. 
No vaginal antisepsis is required except after recent un- 
cleanly contact or in the presence of a pathological vaginal 
secretion, purulent, greenish, yellowish, or ill-smelling. 
The instrument must be aseptic and the operator's hands 
and arms as nearly so as possible. The forceps blades 
may be lubricated with vaselin or glycerin which has 
been sterilized by heat, or simply be dipped in the anti- 
septic solution. A table oil-cloth, a rubber sheet, or an 
old rug is placed under the operator's feet to protect the 
carpet from being soiled by the discharges. 

Application. — The left arm of the forceps is taken in 
the left hand and the blade passed on the left side of the 
pelvis during an interval between the pains. It is at 
first held nearly in a yertical position and lightly as a pen 
is held. Two or more fingers of the right hand are 
passed between the head and the left wall of the passages, 
the palmar surface inward ; the fingers are pushed to the 
base of the skull if possible. The blade is passed along 
the palmar surface of the right hand between the head 
and the wall of the birth-caual, following both the pelvic 



346 



ESSENTIALS OF OBSTETRICS. 



and the cranial curves, hugging the head. (Fig. 66.) 
After the blade has entered the passages the handle usually 
may best be held in the full hand. No force must be 




Application of first blade of forceps. 

used. The right blade is introduced in similar manner, 
the left hand serving as a guide. (Fig. 67.) The blades 
are then adjusted in the best possible grasp as nearly over 
the transverse diameter of the head as possible. The 
blade is pushed sidewise into position by the use of one 
or two fingers against the posterior edge of either rim of 
the fenestra. In high applications sink the handles as 
far backward as the perineum will permit. If the arms 
do not lock readily the blades should be readjusted till 
they do. The locking must never be forced. Guard 



OBSTETRIC SURGERY. 
Fig. 67. 



347 




Application of second blade. 

against pinching the skin or hair of the vulva in the lock 
of the instrument. Before making traction reexamine 
to see that the blades are correctly applied. 

Extraction. — The handles are held lightly near the lock, 
with care to avoid compression of the head. 

The traction should be intermittent — a pull and a pause. 
The pull should coincide with a pain, if possible, and 
should last one minute. Reinforce traction with expressio 
foetus, applied by an assistant. In the intervals of trac- 
tion the instrument should be unlocked to relieve pressure 
on the head. 

Guard Against Slipping. — Readjust the blades to a 
better grasp if they begin to slip. When the head can- 
not be caught primarily over the parietal eminences it 



348 ESSENTIALS OF OBSTETRICS. 

may be necessary to change the grasp, as the head rotates 
in course of descent. The force used must be such only 
as can be applied with the arms without bracing the feet. 
Line of Traction. — The force must act in the direction 
of the birth-canal. In order to this, at the brim, the 
handles are grasped with one hand, and with the other 
downward pressure is applied upon the shanks near the 




Method of applying the traction force in axis of pelvis in operation on low bed- 
(Pa jot.) 

lock (Pajot). (Figs. 68 and 69.) With forceps of mod- 
erate pelvic curve a straight pull on the handles answers 
after the head reaches the pelvic floor. 

Until the head rests on the pelvic floor the direction is 
practically a straight line parallel with the posterior sur- 
face of the symphysis pubis. Then the line of traction 
turns almost directly forward. The handles are sw T ept 
upward until the anterior edges of the blades hug the 
ischio-pubic rami as closely as practicable without crush- 
ing the intervening soft parts. 



OBSTETRIC SURGERY. 



34<) 



When in doubt as to the line of traction let go the 
handles at frequent intervals ; the direction in which they 
point will be that in which the pull should be applied. 



Fig. 69. 




Showing Pajot's manoeuvre for axis traction with plain forceps ; operation on 
high tahle. 

Force. — The force required varies from ten to fifty 
pounds. Time is an important element in a safe forceps 
extraction. It is a familiar principle of mechanics that 
the resistance of a moving body increases as the square 
of the rate of motion. This is not altogether inappli- 
cable in the forceps operation. At least half an hour 
should be taken for a low forceps delivery, more for a 
high operation. 

Perineal Stage. — The instrument may or may not be 
removed during the passage of the head over the perineum. 
Beginners, at least, will succeed best without forceps. 

A half hour or more should be given to the perineal 
stage of delivery except when prompt extraction is de- 
manded in the interest of the child. 



350 ESSENTIALS OF OBSTETRICS. 

Removal of the Forceps. — When the blades are removed 
before the birth of the head the right blade 1 is removed 
first, carrying the handle well up over the opposite groin 
and protecting the soft parts with two fingers placed be- 
tween the ischio-pubic ramus and the anterior edge of the 
blade ; the left is then withdrawn in corresponding manner. 

Occipito-posterior Positions. — Here the forceps operation 
is a dangerous and difficult one. Persistent posterior posi- 
tions of the occiput imply imperfect flexion. The begin- 
ning traction should therefore be made in a somewhat for- 
ward direction, with a view to increasing flexion. For 
the technique of rotation with forceps, see under Treatment 
of Impacted or Arrested Occipito-posterior Position. 

Face Presentation. — In mento-posterior positions as a 
rule, the use of forceps is not permissible. In arrested 
anterior positions of the face the traction should be di- 
rected forward to carry the chin under the pubic arch. 
In mento-posterior positions forceps as a rotator is per- 
missible in skillful hands. 

Breech Presentation. — Here the blades are applied over 
the trochanters, or one over the posterior surface of one 
thigh, the other over the opposite ilium and the sacrum. 
Application over the iliac crests is unsafe owing to the 
danger of injuring the child's abdomen by the pressure 
of the blades and even of serious injury to the bones. 

AXIS-TRACTION FORCEPS. 
The Instrument. — The axis-traction forceps is a plain 
forceps with the addition of traction rods, one attached to 
the heel of each blade by a movable joint at its lower 

1 That on the mother's right. 



OBSTETRIC SURGERY. 351 

end. The lower ends of the traction rods are bent back- 
ward and attached by a universal joint to a cross-bar, 
which serves as a traction handle. (Fig. 70.) By this 




Author's axis-traction forceps. 



construction the pull is directly in line with the axis of 
the blades, and, therefore, with the axis of the passages. 
(Fig. 71.) 



Fig. 71. 




Axis-traction forceps. A B, line of pull in axis of blades. 



352 ESSENTIALS OF OBSTETRICS. 

Advantages. — It reduces the traction force to a mini- 
mum by applying it in the line of descent and hence 
to the best mechanical advantage. It permits the nor- 
mal movements of flexion and rotation as the head de- 
scends. 

Position of Patient. — If the patient lies on a table the 
position is the dorsal recumbent ; on a low bed, the latero- 
prone is better. 

Application. — The blades are adjusted to light pressure, 
and held with the fixation screw. 

Traction. — The pull is applied at the traction bar. 
The handles of the forceps serve to indicate the line of 
traction, which is regulated by keeping the traction rods 
nearly parallel with the forceps handles. The traction 
force should seldom, if ever, exceed fifty pounds. It is 
sometimes advisable in high operations to protect the 
pelvic floor during traction with a Sims speculum or other 
perineal retractor. As a rule, ordinary forceps should be 
substituted after the head has reached the pelvic floor. 

VERSION. 

Version consists in partial or complete inversion of the 
long axis of the foetal ovoid by manual intervention, substi- 
tuting the cephalic or pelvic pole for a less favorable pres- 
entation. 

Cephalic version causes the head to present. 

Podalic version causes the feet to present. 

The term pelvic version applies when any of the ele- 
ments of the pelvic pole of the foetus is substituted for 
some other presenting part. In its restricted sense it re- 
fers to a version which causes the breech to present, an 
operation which is seldom or never called for. 



OBSTETRIC SURGERY. 353 

Indications. — (a) For cephalic version are : Breech 
presentation, if the conditions are favorable (external 
method before labor), shoulder presentation. 

(b) For podalic version are : Flattening of the pelvis 
not below 9.5 cm., 3} inches, c. v.; and equivalent con- 
traction of other forms ; placenta prsevia, simple cases 
excepted ; prolapsed funis not otherwise manageable ; 
most face cases before engagement ; irreducible occipito- 
posterior positions before engagement ; most complex 
presentations ; shoulder presentation when cephalic ver- 
sion is impossible ; certain emergencies demanding rapid 
delivery, head not engaged ; the dead child may gener- 
ally be delivered by podalic version in contraction to 7.5 
cm., 3 inches, c. v. 

Contra-indications to version are firm engagement of 
the head ; high position of the retraction ring ; persistent 
contraction of the uterus, especially in dry labors. In- 
ternal version should be undertaken only after the os is 
fully dilated, or nearly so, and dilatable. The absence 
of liquor amnii, while not a contra-indication, greatly 
embarrasses the operation. 

Dangers of Version. To the Mother. — In external and 
in bipolar version the dangers are usually insignificant. 
Rupture of the uterus has occurred in difficult cases. 

In internal version there is danger of uterine rupture 
and increased risk of sepsis. Rapid extraction following 
version increases the danger of laceration and also of shock. 

To the Child. — The dangers to the child in internal ver- 
sion are possible fracture of the bones, compression of the 
spine, and the usual risks of ordinary breech-birth. 

Operation. — Most essential is an exact knowledge of the 
capacity of the pelvis, the size of the foetal head, and the 
23 



354 ESSENTIALS OF OBSTETRICS. 

presentation and position of the foetus. Make a thorough 
examination after the patient is anaesthetized. For internal 
version the passages must be fully dilated or easily dilatable. 
If immediate delivery is intended the usual preparations 
for a breech extraction should be made. The operation 
is best conducted on a table. Two assistants beside the 
anaesthetist should be had if possible. 

A. External Version. 

External version is applicable, as a rule, only before 
labor. It is permissible when it can be done without 
violence. 

Method. — Placing the hands upon the abdomen, one 
over each foetal pole, the poles are pushed in opposite direc- 
tions. The manipulation is practised between the pains. 
During the pains the foetus is held to prevent reversion to 
the former presentation. Finally, after the version is com- 
plete, a binder and lateral compresses are applied over the 
abdomen to prevent recurrence of the malpresentation. 

B. Bipolar Version. 

Advantages of the bipolar over internal version are : A 
minimum of traumatism and shock ; less danger of infection. 
The fact that it may be done early in the first stage of labor 
is a distinct gain in placenta praevia. The bipolar should 
be preferred to the internal method when practicable. 

Method. — As a rule anaesthesia is necessary. The 
bladder and rectum must be empty. The patient is placed 
in the dorsal recumbent position. The manipulation is con- 
ducted between the pains. A strict asepsis is imperative. 
One or two fingers of one hand are passed through the cer- 
vix, and the other hand is placed over the opposite foetal 



OBSTETRIC SURGERY. 355 

pole externally. With the external hand the breech is 
pushed toward the side on which the feet lie. (Fig. 72.) 

Fig. 72. 



First stage of bipolar version. Elevation of the head and depression of the 
breech . ( After Barnes. ) 



With the internal hand the head is tossed out of the excava- 
tion into that iliac fossa toward which the occiput points 
(Fig. 73) ; the trunk is pushed along in the same direction, 
inch by inch, till a knee presents. (Fig. 74.) The knee is 
drawn down and the foot extracted. (Fig. 75.) The other 
foot also may be brought down if easily accessible. The 



356 



ESSENTIALS OF OBSTETRICS. 
Fig. 73. 




Second stage of bipolar version. Elevation of the shoulder and depression of the 
breech. (After Barnes..) 



Fig. 74. 




Third stage of bipolar version. Seizure of the knee and partial elevation of the 
head. (After Barnes.) 



OBSTETRIC SURGERY. 



357 



labor is henceforth to be conducted as in spontaneous 
breech cases. The operator should cease manipulation 
during uterine contractions. 

A bipolar manipulation is applicable in cephalic version 
also. 

Fig. 75. 




Fourth stage of bipolar version. Drawing down the legs and completion of version. 
(After Barnes.) 



C. Internal Version. 

Method. — The patient is placed in the dorsal recum- 
bent position under an anaesthetic. In difficult cases the 
knee-chest or the Trendelenburg position may be utilized. 

The clothing of the operator is covered with a sheet or 
operating gown. The passages, their approaches, and 



358 ESSENTIALS OF OBSTETRICS. 

the operator's hands must be surgically clean. The oper- 
ator should wear rubber gloves with gauntlets. 

One hand is passed into the uterus over the abdomen of 
the child, palmar surface toward the child. Either foot or 
both feet are seized and the foetal ovoid is inverted by 
traction. If a hand is within reach it is snared and held 
down sufficiently to prevent extension. A prolapsed arm 
should be pushed above the brim. The other hand of 
the operator may be used externally to steady the fundus 
or to assist the rotation of the child by pushing up the 
cephalic pole. The operator relaxes the hand and desists 
from manipulation during the pains. To prevent cramp- 
ing of the hand the manipulations should be carried out 
with the least possible muscular effort. 

The completion of the birth is managed as in ordinary 
breech extractions. 

OBSTETRIC SURGERY OF THE ABDOMEN. 

CESAREAN SECTION: CCELIO-HYSTEROTOMY. 

Definition. — Csesarean section is an operation for ex- 
traction of the child by section of the abdominal and the 
uterine walls. 

Historical Note. — This operation antedates the Chris- 
tian era. The earlier Cesarean sections, however, were 
post-mortem operations done a few minutes after the 
death of the mother to save the child. The earliest 
Cesarean section upon the living subject of which we 
have any knowledge was performed in the year 1500. 

Capabilities of the Modern Operation. — Timely 
operations under the modern (Sanger) method and in 
favorable conditions should save not less than 95 per 



OBSTETRIC SURGERY. 359 

cent, of the mothers, and the chances for the children 
should be as good as in spontaneous births. The maternal 
mortality is very great in operations delayed till the 
woman is exhausted by long labor and by attempts at de- 
livery by other means, especially if exhaustion is compli- 
cated with sepsis. The foetal death-rate also is increased 
in late operations. 

Indications. — With a living and viable foetus, the 
woman in operable condition, the head being of average 
size, Csesarean section is indicated in flattened pelves, 
when the conjugate is below 7 cm., 2f inches, and in 
other forms of contraction in which there is equivalent 
disproportion between the head and the pelvic space ; 
generally with dead foetus, when the conjugate is below 
6.3 cm., 2 J inches, and in cancer of the cervix, when de- 
livery per vias naturales is impracticable. 

In lesser grades of obstruction Csesarean section may 
be chosen in preference to its alternatives, symphysiotomy, 
induced premature labor and even very difficult delivery 
by forceps or version if all conditions are favorable. 

When the degree of obstruction is such that the de- 
livery of a living child is impossible by other means, 7 cm. 
or less, c. v., the indication is said to be absolute. When 
other operative methods are practicable in a given case, 
and the Csesarean operation is elected, it is said to be done 
on the relative indication. 

It would be better if the upper limit of the absolute in- 
dication were advanced to 7.5 cm. in simple flat pelves 
and to 9 cm. in generally contracted pelves as Whitridge 
Williams suggests. 

The preferred time for operating is a few days before 
the expected date of labor. Operation at an appointed time 



360 ESSENTIALS OF OBSTETRICS. 

before labor permits better preparation, the patient's con- 
dition is better, the uterus retracts as well as in operation 
during labor, and drainage is all-sufficient or can be made 
so. There is a distinct advantage in operating before rup- 
ture of membranes since there is less traumatism, the child 
is more certainly viable and extraction is easier. 

Preparatory Measures. — If necessary, the patient's 
strength should be reinforced by tonics and hygienic 
measures. The bowels are thoroughly opened the day 
before operating. 

The bladder should be emptied and the rectum washed 
out immediately before the operation. 

Instruments should be sterilized by boiling for ten 
minutes in 1 J per cent, solution of washing-soda. 

The hands and arms of the operator and assistants 
should be sterilized and their clothing covered with 
operating-gowns which have been steamed for a half-hour 
immediately before using. Operator, assistants, and 
nurses wear muslin caps fresh from the steam-chamber to 
cover the hair. 

The abdomen is prepared as follows : On the evening 
before operation, after a total bath and a change of linen — 

Cover the entire abdomen with a green soap dressing 
for three hours ; 

Scrub ten minutes with a soft, sterile brush, green soap 
and hot water ; 

Shave the entire surface with a sterile razor ; 

Re-scrub ; 

Flush w T ith sterilized w T ater ; 

Wash with alcohol, using a pledget of aseptic cotton ; 

Flush for five minutes with the mercurial solution 
(1 : 2000) ; 



OBSTETRIC SURGERY. 361 

Cover all with a compress well wet with the mercurial 
solution, covered with oiled silk and held with a binder. 

On the morning of operation the entire field is covered 
with a compress wet with Labarraq lie's solution 1 : 10 or 
a formalin solution 1 : 250, which is removed just before 
the first incision. 

In emergency cases the antisepsis must be as complete 
as the limited time allows. 

The temperature of the room should be 75° to 80° F. 

The patient is placed in the horizontal position and the 
body and extremities are wrapped warmly with clean 
flannels, except the operative field. The clothing about 
the field of operation is covered with dry cloths or tow- 
els sterilized by steaming for half an hour, and finally a 
sheet fresh from the steam chamber and provided with an 
opening to expose the field of operation is spread over 
the patient and top of table. 

A sheet of Murphy's adhesive rubber dam over the 
entire abdomen next the skin is a valuable precaution 
against infection. The incision is made through it. 

Assistants. — The first assistant stands on the left of 
the patient, opposite the operator. Another gives the an- 
aesthetic. A nurse or third assistant takes charge of the 
steam sterilizer and the instruments. Another assistant 
stands ready to receive the child. 

Instruments. — Scalpel ; straight scissors ; two thumb- 
forceps ; six to twelve haemostatic- forceps ; needle-holder 
and needles ; long catch forceps for holding sponge com- 
presses ; a large, thin- walled rubber tube, 1.25 meter 
(about four feet) long, as a constrictor for the neck of the 
uterus; a steam sterilizer for sterilizing cheese cloths, 
towels,' etc., twelve No. 3 catgut sutures for the deep 



362 ESSENTIALS OF OBSTETRICS. 

uterine suture ; twelve No. 1 catgut sutures for the super- 
ficial uterine suture or a single continuous suture; a plain 
continuous 00 catgut suture for suture of the parietal 
peritoneum ; twelve silkworm-gut sutures for deep abdo- 
minal sutures ; twelve plain No. 3 catgut sutures for closing 
the fascia or a single continuous catgut 18 inches long; 
several dozen gauze compresses to be used for sponging. 

Summary of the Conditions of Success. — The elective 
operation ; a perfectly aseptic technique ; deep uterine 
sutures, three to the inch ; superficial or half-deep between 
the deep sutures ; maintenance of the natural temperature 
of the abdominal contents ; the least possible handling 
of peritoneal surfaces ; operation within thirty to forty 
minutes. 

Steps of the Operation. — 1. Median incision of the 
abdominal wall ; 

2. Application of the uterine constrictor about the 
lower uterine segment or manual control ; 

3. Median incision of the uterus ; 

4. Extraction of the child and placenta ; 

5. Closure of the wounds and application of the ab- 
dominal dressing. 

Technique of the Operation. — The operator assures 
himself that there is no loop of intestine between the 
uterus and the abdominal wall, beneath the field of in- 
cision. Should a coil of intestine be found here it is 
pushed above the fundus. 

An assistant holds the uterus in central position. The 
skin incision extends from just below the navel to a point 
an inch above the symphysis, uncovering the linea alba. 
The tendon is divided, exposing the subperitoneal fat. 
Should the incision miss the linea alba and enter one of 



OBSTETRIC SURGERY. 363 

the rectus muscles, separate the muscular buudles with 
the scalpel handle, pick up the fascial layers beneath with 
the forceps and divide them down to the retro-peritoneal 
fat. Bleeding vessels are held by catch-forceps or ligated 
before opening the peritoneum. The fat is pushed aside 
and the peritoneum lifted with thumb-forceps and nicked 
with the scalpel or scissors close to the forceps, and the 
incision extended to nearly the full length of the first 
incision on the finger as a guide. An assistant injects into 
the thigh hvpodermically 5ss of fluid extract of ergot. 

A loop of the constrictor is passed over the fundus and 
adjusted around the cervix ; it is tightened only as neces- 
sary to control hemorrhage ; or the constrictor may be 
dispensed w T ith, the assistant encircling the lower seg- 
ment of the uterus with his hands and using compression 
as required for the prevention of bleeding. 

A short longitudinal median incision is made in the 
uterine wall well above the retraction ring, avoiding the 
membranes if still unbroken. This is lengthened up- 
ward with the fingers or scissors to a point short of the 
fundus. The length of the uterine incision should not 
exceed 15 cm., 6 inches. 

The hand is thrust through the membranes and the 
child extracted by the head or the feet. 

In case of anterior implantation of the placenta, it is 
separated at one edge and pushed aside, or the hand may 
be passed directly through it. 

The cord is clamped at two points with catch-for- 
ceps, cut between them, and the child is passed to an as- 
sistant. 

The uterine incision may be made at the fundus in the 
sagittal plane (Muller) or transversely extending between 



364 ESSENTIALS OF OBSTETRICS. 

the Fallopian tubes (Fritsch), but these incisions offer no 
material advantage. 

If the uterus slips out of the abdomen the intestines 
are kept back, if necessary, with hot sterilized towels 
placed over the upper part of the incision. The cover- 
ings help also to protect the peritoneum from soiling. 
The uterus is wrapped in hot moist cloths. 

The placenta, if not spontaneously separated, is peeled 
off by grasping it with one hand like a sponge. If the 
cervix is not sufficiently open for drainage it is dilated 
instrumentally or manually. 

Irrigating or mopping the uterine cavity is unnecessary. 
Asepsis is promoted by leaving it as nearly as possible un- 
touched. Irritating the peritoneum by handling, needless 
sponging, or contact of chemical antiseptics should be 
avoided. 

The uterine wound is closed with deep No. 3 catgut 
sutures at intervals of 1 cm., about j- inch. They are 
entered 1.3 cm., J inch, from the incision and passed 
obliquely inward, falling short of the decidua. 

The peritoneal coat of the uterus is closed with inter- 
rupted sutures of No. 1 catgut between the deep sutures 
dipping into the muscular coat, or a continuous suture 
may be preferred. 

Remove the constrictor and secure retraction of the 
uterus, if necessary, by manipulating it through a hot 
towel or by faradism. Pul] down the omentum over the 
uterus. 

If liquor amnii or much blood has escaped into the 
peritoneal cavity, it should be removed completely by 
gentle sponging. When there has been much blood-loss 
a quart or two of warm sterilized 0.7 per cent, salt solu- 
tion may be left in the peritoneum. 



OBSTETRIC SURGERY. 365 

The parietal peritoneum is closed with a plain running 
No. 00 catgut suture. 

Interrupted si Ik worm -gut sutures are then passed at 
intervals of 2 cm., about f inch, through all but the peri- 
toneum from within outward. 

The fascia is brought together with interrupted No. 3 
plain catgut sutures, the skin may be closed with a run- 
ning cutaneous or a subcuticular suture of plain catgut. 
Usually no special skin suture is required. 

The silkworm-gut sutures are now tied. The abdom- 
inal wound is dressed with several thicknesses of dry 
sterilized cheese-cloth held in place by an abdominal 
binder. 

After-Treatment. — To promote reaction the bed is 
warmed with hot- water bags, and the patient's head is 
wrapped in flannel ; an injection of whiskey oij or black 
coffee 5iv and hot water Sviij, may be given by the rec- 
tum if required. 

An eighth grain of morphin or twice as much codein 
may be given subcutaneously in case of much pain or 
restlessness. As a rule this should not be repeated and 
none is needed after the first night. 

The bladder should be emptied every eight hours, but 
the catheter should be withheld if possible. 

The child is put to the breast as in normal cases. Two 
teaspoonfuls of hot water may be given every hour. 

For the Mother. — Feeding is begun with light liquid 
food as soon as it can be retained, within twelve to twenty- 
four hours usually. 

The bowels are opened with salines on the second or 
third day after operation, sooner should evidence of infec- 
tion appear. 



366 ESSENTIALS OF OBSTETRICS. 

The silkworm-gut sutures are removed by the four- 
teenth day. 

The patient can usually leave the bed at the end of 
three weeks. A firm abdominal binder or supporter 
should be worn for two or three weeks after operation. 

Post-mortem Caesarean Section. — In case of sudden 
death of the mother in the last month of gestation, the 
child usually may be delivered alive by abdominal section, 
if extracted within five minutes after the mother's death. 
It is stated on good authority that in exceptional instances 
the child may survive in utero for several hours after 
death of the mother. The child is saved in only about 5 
per cent, of post-mortem Cesarean sections. 

PORRO OPERATION: CCELIO-HYSTERECTOMY. 

Definition. — A Csesarean section, supplemented by su- 
pravaginal amputation of the uterus and removal of the 
tubes and ovaries. 

The operation is named after Edward Porro, of Pavia, 
Italy, who w T as first to perform it, in 1876. The results 
in equally favorable conditions should not fall much short 
of those attained in simple Cesarean section. 

Indications are myomata of the uterus ; disease of the 
uterus or appendages requiring their removal ; marked 
puerperal osteomalacia ; probable uterine infection ; un- 
controllable hemorrhage after Caesarean section ; vaginal 
atresia obstructing drainage. 

Steps of the Operation. — Abdominal incision, as in 
Cesarean section ; eventration of the uterus ; constriction 
of the cervix with a finger-thick rubber tube, passing loop 
over the fundus, the ovaries and tubes being held up ; 
packing hot cloths about the cervix to keep blood and liquor 



OBSTETRIC SURGERY. 367 

amnii from soiling the peritoneum ; incision of the uterus 
and extraction of child and placenta ; transfixion of the 
cervix by passing two or three knitting-needles or hat-pins 
at different angles through the constricting rubber-tube 
and the cervix ; amputation of the uterus 2 cm., f inch, 
above the constrictor ; ligation of the uterine arteries in 
the stump or at the sides of it ; stitching the entire cir- 
cumference of the stump in the lower angle with the free 
surfaces of peritoneum in contact ; suture of the abdominal 
wound ; mummification of stump with perchloride of iron 
solution ; abdominal dressings as in Cesarean section. 

This operation is practically superseded by the usual 
modern method of supravaginal amputation. The tech- 
nique, after the uterus is evacuated, does not differ from 
that of abdominal hysterectomy as done for fibroids. The 
after-treatment, too, is the same. 

SYMPHYSIOTOMY. 

Historical Note. — Division of the pubic joint for the 
purpose of facilitating delivery in narrow pelves was first 
done on the living woman in France by Jean Rene 
Sigault in 1777. Meeting partial acceptance for a time, 
the operation, after a half century, had become practically 
obsolete. Revived by Morisani, of Naples, Italy, in 
1866, it was taken up in the country of its birth by 
Pinard early in 1892. His success and advocacy led to 
its immediate adoption throughout the world. 

Results. — The maternal mortality differs little from 
that of Cesarean section under equally favorable condi- 
tions. The foetal death rate at the best is somewhat 
greater. The mortality for both patients, however, has 
been increased by operations performed on pelves too 



368 ESSENTIALS OF OBSTETRICS. 

small. Restoration of the symphysis, as a rule, is com- 
plete. Possible complications of the operation are lacera- 
tion of the anterior soft parts, including the urethra and 
bladder, and hemorrhage, more rarely suppuration of the 
symphysis and injury to the sacro-iliac joints. 

Space Gained. — The maximum pubic separation per- 
missible, according to most authorities, is 7 cm., 2 J 
inches ; with an interpubic opening of that extent the 
conjugata vera gains a little more than 1.3 cm., J- inch. 
The transverse at the brim gains once and a half, the 
oblique about twice as much as the conjugate does. The 
parietal boss projects into the interpubic space, and this 
is equivalent to a slight additional increase in the con- 
jugate. 

Indications. — Simple flattening of the pelvis not be- 
low 7 cm., 2| inches, or better 7.5 cm., 3 inches, in the 
conjugate, or equivalent disproportion from other causes; 
irreducible occipito-posterior positions ; firmly impacted 
mento-posterior face cases, and irreducible brow presenta- 
tion. The operation is contraindicated in ankylosis of 
one or both sacro-iliac joints. The foetus must be living 
and viable. With a dead or non-viable child craniotomy 
should be substituted. 

Method of Operating. — The patient lies in the dorsal 
position, with the thighs strongly flexed and the knees 
held apart, under an anaesthetic. The antiseptic prepa- 
ration of the abdomen is the same as for coeliotomy. The 
vulva and vagina are prepared with the same care as the 
abdomen. The cervix must be fully dilated. A metallic 
catheter is passed into the bladder by an assistant and 
pressed backward and to one side. This helps to protect 
the urethra and vesical neck from injury, and, at the 



OBSTETRIC SURGERY. 



369 



same time, keeps the bladder empty. The abdominal 
incision may be long or short. The long incision begins 
an inch above the top of the symphysis, and is carried 



Fig. 76. 




Incision in symphysiotomy by the open method; dividing the suspensorv ligament 

of the clitoris. (Farabeuf. ) 

down over the anterior surface of the joint — the open 
method; the short incision is from one to three inches in 
24 



370 



ESSENTIALS OF OBSTETRICS. 



length, and terminates below at the top of the symphysis 
— the subcutaneous method. The advantage of the 
former is that the steps are conducted under direct in- 
spection ; it is claimed for the latter that the wound is 
less exposed to infection by the lochia. The open method 
is recommended. 

In the open method the division of the joint is con- 
ducted as follows : The incision exposes the entire length 
of the joint, extends an inch above it, and opens the 



Fig. 




Showing clitoris drawn down after division of its suspensory ligament,. and the 
pubic arch laid bare. (Faeabeuf.) 



OBSTETRIC SURGERY. 371 

space between the recti muscles. The clitoris is drawn 
down with a sharp hook caught just above it, its sus- 
pensory ligament cut (Fig. 76), and the bony margin of 
the pubic arch laid bare by detaching from it the trian- 
gular ligament with a few strokes of the scalpel. (Fig. 
7f.) 

The retro-pubic structures are pushed back with the 
finger passed down behind the symphysis, a broad 
strongly curved director is passed immediately behind 
the joint from below upward or from above downward. 
The clitoris and other vascular structures at the lower 
end of the symphysis are thus held back during the 
division of the joint. This prevents hemorrhage, which 
is otherwise sometimes a serious complication. 

The joint is located by finding the notch at the top be- 
tween the pubic bones or by forcibly flexing and extend- 
ing one lower extremity while the other is held stationary. 

The symphysis is then divided with a strong, slightly 
curved, blunt-pointed bistoury from behind forward or 
from before backward. 

The bones are cautiously separated and held apart to 
the extent of 7 cm., 2 j inches, the lateral halves of the 
pelvis being firmly supported by the assistants to pre- 
vent further separation as the head is forced down. 

In the subcutaneous method the incision is from 2.5 to 
7.5 cm., 1 to 3 inches, in length, according to the thick- 
ness of the abdominal walls, and it terminates below at the 
top of the symphysis. It is carried down between the 
rectus muscles. The finger is passed behind the symphysis, 
and the joint divided by the bistoury from behind for- 
ward and from above downward, the finger serving as a 
guard and a guide. 



372 ESSENTIALS OF OBSTETRICS. 

Venous hemorrhage, which is sometimes profuse, is 
controlled by pressure by packing the wound and, if 
necessary, the vagina with sterilized gauze or by haemo- 
static suture. The short incision may be extended should 
it become necessary for the control of hemorrhage or by 
reason of other complications. 

When, owing to bony ankylosis or to the sinuous course 
of the symphysis, division with the knife is impossible, 
the joint may be opened with a metacarpal or chain saw. 

The child is extracted with forceps if it is not promptly 
expelled by the natural forces. Bilateral episiotomy should 
be done, if necessary, to prevent laceration of the anterior 
soft parts at the vaginal outlet. Great care must be used 
during delivery to prevent laceration of the anterior 
vaginal wall. 

After delivery of child and placenta, the bones are 
brought together firmly, the urethra and the vesical neck 
being meantime held backward to avoid pinching between 
the bones. 

The soft parts are closed with silkworm-gut sutures, 
which, in the open method of operating, should include 
the fibrous structures in front of the joint. Two or three 
strands of silkworm-gut may be carried down from be- 
hind the joint as a drain. This is removed in twenty- 
four hours. Zweifel sutures the fibrous structures with 
catgut and leaves the superficial wound open for 8 or 10 
days, packing it with gauze. 

The pelvis is immobilized by means of two or three 
strips of rubber adhesive-plaster, reaching obliquely from 
one side of the pelvis to the other, above the wound, and 
over these a firm binder. The patient lies, moreover, 
during convalescence, on the back in a hammock-bed 



OBSTETRIC SURGERY. 373 

(Avers), or on two firm cushions which support the lateral 
halves of the body and the pelvis. A canvas binder 
provided with straps and buckles for fastening makes a 
firm and easily adjustable support. 

An ounce or two of boric acid, 1 : 8, may be left in 
the vagina. 

After-treatment. — For three or four weeks the pa- 
tient should lie on the back with the limbs outstretched. 
The urine may need to be drawn with a catheter for the 
first two or three days after operation. 

The binder is changed as often as soiled. The sutures 
are removed by the eighth or tenth day. The patient is 
kept in bed for four weeks. The binder remains six 
weeks. 

EMBRYOTOMY. 

Embryotomy is the general term for all obstetric oper- 
ations employed to facilitate delivery through the natural 
passages by lessening the size of the foetus. 

Indications are hydrocephalus too large for safe extrac- 
tion Avithout perforating and not manageable by aspiration 
of the cranial cavity ; obstructed labor with a dead or non- 
viable foetus or a foetal monstrosity, conjugate exceeding 
2 J inches ; and impacted shoulder or face presentation if 
the child is dead. 

It is very rarely that embryotomy will be justifiable on 
the living and viable child. The sacrificial operation 
must be considered as an alternative of Cesarean section 
or symphysiotomy when the condition of the mother 
is unfavorable for the latter operations, and especially 
if she elects the former with a full knowledge of the 
facts. 



374 ESSENTIALS OF OBSTETRICS. 

CRANIOTOMY. 

Definition. — An operation for the comminution and re- 
moval of all or a portion of the cranial bones to facilitate 
delivery. 

Steps. — 1. Perforation. The field of operation should 
be cleansed and disinfected and the woman placed on the 
table, in the obstetric position and under an anaesthetic. 
All but the operation field is covered with an aseptic sheet. 
The instrument may be a Smellie's scissors or Naegele's 
perforator (Fig. 78), preferably the trephiue. In emer- 
gency a long, sharp-pointed surgical scissors will serve the 
purpose. The bladder and rectum should be empty. An 
assistant steadies the head by grasping it above the brim 
with the hands placed over the abdomen. 

Fig. 78. 




Naegele's perforator. 

The point of the perforator is pressed against the head, 
perpendicularly to the surface of contact, just behind the 
pubic bones, the finger of one hand serving as a guard. 
Except when the trephine is used the puncture is best made 
through a suture or fontanelle. 

The point is fixed in the tissues by a screw-like mo- 
tion, and perforation is then effected by a similar motion. 

The blades are separated in different directions to en- 
large the opening. 

The most approved method of perforating is with the 
trephine. It removes a button of bone, leaving a per- 



OBSTETRIC SURGERY. 375 

ma lien t opening through which the cranial contents niay 
readily be evacuated. 

The after-coming head may be perforated through a 
skin incision made at the base of the neek posteriorly ; 
the perforator is passed subcutaneously. 

The brain is broken up with the perforator and washed 
out with a stream of sterilized water forcibly injected 
with a Davidson's syringe. 

2. Comminution. — With the craniotomy forceps passed 
within the scalp, the cranial bones are seized, one by one, 
and dislodged by rotating the forceps about its long axis 
and then removed. In moderate obstruction the head 
may be crushed and extracted with a cephalotribe. 

In the higher grades of pelvic contraction the cranial 
base, as well as the vault, has been broken up. Tarnier's 
basiotribe was devised for this purpose. Between its 
blades is a screw perforator, which is made to perforate 
the head, while the blades crush it. With the resources of 
modern obstetric surgery basiotripsy is scarcely necessary. 

3. Ext faction is effected with the craniotomy forceps 
or, when space permits, with the cephalotribe, guarding 
carefully against laceration of the passages by projecting 
spicula of bone. If craniotomy forceps is used, one 
blade is passed within and one without the cranial cavity. 
In extreme narrowing the cranial base is best delivered 
edgewise by drawing dowm the chin. 

CEPHALOTRIPSY. 

Cephalotripsy is an operation for reducing the size of 
the head by crushing the cranial vault. The best cepha- 
lotribe is Lusk's. (Fig. 79.) 

The method of application does not differ from that of 



376 ESSENTIALS OF OBSTETRICS. 

the obstetric forceps. An assistant crowds the head 
firmly into the excavation if it is not already engaged. 
The head is perforated and the cephalotribe is applied 
with care to secure a good grasp. 

The skull is then sloAvly crushed by turning a power- 
ful screw at the handles. The head is brought down with 
the cephalotribe used as a tractor. Since the cranial 
vault is expanded in one direction as it is crushed in the 
opposite, care must be used to guard against laceration 




Lusk's cephalotribe. 

of the passages by projecting spicula of bone. The elon- 
gated diameter of the head must be kept in the long 
diameter of the pelvis. 

Cephalotripsy is practicable only in moderate con- 
traction. 

EVISCERATION. 

This term applies to all operations for reducing the size 
of the trunk by removal of its viscera. The operation is 
limited almost wholly to cases of impacted shoulder in 
which decapitation would be difficult or impossible. 

Perforation of the trunk may be done with a craniotomy 
perforator, or through the bony coverings of the chest 
with the trephine. The viscera are then broken up with 
the perforator and removed with craniotomy forceps, with 
stout dressing-forceps, or with the fingers. The bony 



OBSTETRIC SURGERY. 377 

walls, if necessary, may be cut away piecemeal with 
strong scissors. 

Sometimes the trunk is divided into sections with a 
chain saw, or stout blunt scissors, and delivered piece- 
meal. The head is then crushed and extracted with the 

cephalotribe. 

Fig. 80. 





Braun's hook. 

DECAPITATION. 
Methods. 1. Blunt Hook and Scissors. — While an as- 
sistant draws the neck firmly down with a blunt hook or 
a strong tape passed around the neck, the neck is gradu- 
ally severed with blunt-pointed scissors guarded by two 
fingers of the other hand. 



378 ESSENTIALS OF OBSTETRICS. 

2. Braun's hook is a convenient and safe instrument 
for decapitation. (Fig. 80.) The hook is passed flat- 
wise on the hand as a guide. It is carried up between 
the head and the pubic bones till it can be hooked over 
the neck. The neck is then firmly engaged in the hook 
by traction. By a to-and-fro movement of the handle the 
neck is readily severed. 

3. Eeraseur. — A tape is passed around the neck as 
follows : It is first well oiled and knotted at one end ; 
the knot is pushed up over one side of the neck with the 
fingers of one hand, the fingers of the other hand catch- 
ing it and pulling it down on the other side. Another 
method of carrying the tape into place is with an English 
bougie properly curved and armed with a stylet. The 
chain of the 6craseur is attached to the tape and drawn 
into place. The neck is then cut through by tightening 
the chain. 

A wire eeraseur armed with piano-wire or common 
picture-wire may be used for the purpose, or a chain saw 
may be substituted for the eeraseur. 

Extraction. — After decapitation the head is pushed up 
and the trunk delivered ; then the head is extracted, 
chin first. Two fingers of one hand are hooked in the in- 
ferior maxilla and the head crowded through the pelvis 
by suprapubic pressure with the other hand or delivered 
with forceps or omphalotribe. In a narrow pelvis it may 
be necessary to crush the head before it can be delivered. 
Perforation may be clone in the grasp of the omphalotribe 
and the cranial contents then be broken up and removed 
in the usual manner. Care must be taken lest the uterus 
be ruptured in these manipulations or the passage be 
lacerated by projecting bone-fragments. 



INDEX. 



ABDOMEN, obstetric surgery of, 
_ 358 
pigmentation of, in pregnancy, 

78 . 
Abdominal binder, 170 

enlargement from other causes 

than pregnancy, 87 

in pregnancy, 78 

examination for presentation and 

position of foetus, 131 

signs of pregnancy, 73 

Abortion, 219 

causes of, 220 

diagnosis of, 220 

incomplete, 225 

induction of, 337 

indication for induction of, 337 

methods of, 338 

treatment of, 222 

Accidental hemorrhage, 299 

causes of, 299 

diagnosis of, 300 

treatment of, 301 

varieties of, 299 

Adherent placenta, removal of, 340 

After pains, 174 

treatment of, 177 

Allantois, 56 

Amnion, 54 

anomalies of, 208 

Anaemia, acute, treatment of, 292- 

298 

in pregnancy, 239 

Anaesthesia in labor, 154 

method of, 156 

Anomalies of foetal development as 

causes of dystocia, 278 

Ante-partum examination, 130 

Antisepsis in labor, 145 

in puerperium, 177 



Areolae of breasts, changes in pri- 
mary during pregnancy, 75 
secondary, 77 
Armamentarium, obstetric, 143 
Artificial feeding of newborn child, 

190 
Asphyxia neonatorum, 184 
treatment of, 184 
Byrd's method, 186 
direct insufflation, 185 
faradism, 186 
Laborde's method, 186 
Schultze's method, 185 
Sylvester's method, 185 
Atresia, vaginal, as a cause of 
dystocia, 254 
vulvar, as a cause of dystocia, 
254 

BAG of waters, 121 
Ballottement, internal, as sign 
of pregnancy, 86 
Bartholin, gland of, 23 
Binder, abdominal, 170 
Bladder, evacuation of, after labor, 

176 
Blastoderm, 52 
Blastodermic vesicle, 52 
Bowel movements, regulation of, in 

puerperium, 176 
Breech presentation, 266 
causes of, 266 
diagnosis of, 267 
mechanism of, 266 
prognosis of, 268 
treatment, 268 
Brow presentation, 264 

treatment of, 265 
Bulbi vestibuli, 23 
Bulbo-cavernosus muscle, 111 



380 



INDEX. 



p^ESAKEAN section, 358 
\J after-treatment of, 365 
capabilities of, 358 
indications for, 359 
post-mortem, 366 
preparatory measures for, 360 
steps of operation, 362 
technique of, 362 
Caput succedaneum, 127, 184 
Care of the breasts and nipples 

during lactation, 181 
Cardiac disease as a complication 

of labor, 312 
Caruncuia? myrtiformes, 24 
Catheter, use of, 178 
Cephalhematoma of newborn 

child, 201 
Cephalotripsy, 375 
Cervix, cancer of, as a cause of 
dystocia, 255 
rigidity of, as a cause of dystocia, 

255*' 
uteri, purplish color of, in preg- 
nancy, 83 
softening, in pregnancy, 83 
Cervical lacerations, 162 
method of suture, 162 
Child, care of premature, 336 
condition of, at birth, 182 
newborn, bathing of, 186 

blood v genital discharge in, 

206' 
cephalhematoma in, 201 
circulation of, 182 
clothing of, 188 
colic in, 199 
constipation in, 198 
diarrhoea in, 200 
disorders of, 198 
genito-urinary organs of, 183 
icterus in, 202 
indigestion in, 199 
intertrigo in, 201 
management of, 184 
mastitis in, 206 
newborn, navel dressing of, 

187 
nursing, 188 

contraindications to, 181 
ophthalmia in, 203 
preputial adhesion in, 202 
respiration of, 184 



Child, skin of, 183 
tetanus in, 205 
thrush in, 200 
umbilical hemorrhage in, 206 

infection in, 205 
weaning, 189 
weight of, 182 
wet-nursing, 189 
Choc foetal, 81 
Chorial villi, 58 
Chorion, 57 

cystic degeneration, 210 
diseases of, 210 
frondosum, 59 
lseve, 59 

vesicular mole, 210 
Clitoris, anatomy of, 21 
Celio-hysterectomy, 366 

-hysterotomy, 358 
Colostrum, 180 
Colpitns, puerperal, symptoms of, 

324 
Complex presentations, treatment 

of, 277 
Conception, 50 
Cord, ligation of, 159 
management of, 159 
Corpus luteum, 49 
Craniotomy, 374 

steps of, 374 
Cystitis, puerperal symptoms of, 
324 
treatment of, 329 
Cystocele as a cause of dystocia, 254 



DECAPITATION, 377 
methods of, 377 
Deciduse, 59 

diseases of, 207 
Deficient lactation, signs of, 180 
measures for increasing the 
milk secretion in, 180 
Diabetes mellitus as a complication 

of labor, 312 
Diameters of foetal head. See Foetal 
head, measurements of. 
of trunk, 116 
of pelvis, external, 104 
internal, 103 
measurement of, 140 
Diet of puerperal patient, 177 



INDEX. 



381 



Dilatation, stage of, management 
of, 152 
measures for relief of pain in, 

152 
special directions for manage- 
ment of, 152 
vaginal examinations in, 152 
Disorders of the new born infant, 198 
Double monsters, 280 
Draw-sheet, 170 

ECLAMPSIA, 305 

lJ clinical phenomena of, 307 

etiology of, 306 

prognosis of, 307 

treatment of, 308 
Ectopic gestation, 226 

clinical course of, 227 

diagnostic signs of, 229 

etiology of, 227 

treatment of, 232 

varieties of, 226 
Embryo, development of, 53 

rate of, 64 
Embryotomy, 373 

indications for, 373 
Endometritis, puerperal, 322 
Episiotomy, 157 
Evisceration, 376 
Expelling forces, regulation of, 156 

powers, 96 
Expulsion, stage of, management 
of, 153 

vaginal examination in, 154 
Extra-uterine pregnancy. See 
Ectopic gestation. 

FACE presentation, 260 
causes of, 260 
diagnosis of, 261 
mechanism of, 260 
prognosis of, 262 
treatment of, 262 
Fallopian tubes, anatomy of, 39 
Foetal circulation, 67 
death, 217 

treatment in, 219 
development, anomalies of, as 

causes of dystocia, 278 
head, obstetric anatomy of, 112 
diameters of. See Foetal head, 
measurements of. 



Foetal head, fontanelles of, 112 
measurement of, 113 
protuberances of, 113 
sutures of, 112 
heart -tones as a sign of preg- 
nancy, 81 
membranes, development of, 

54 
movements, active, as a sign of 
pregnancy, 79 
passive as a sign of pregnane v, 
80 
Foetus, anomalies of development 
of, 215 
as a cause of dystocia, 278 
changes in, after death in utero, 

218 
death of. See Fcetal death, 
diseases of, 216 
length of in later months of 

pregnancy, 92 
pathology of, 215 
position of, 117 
posture of, 118 
presentation of, 116 
tumors of, as a cause of dvstocia, 

282 
rate of development of, 64 
Fontanelles of foetal head, 112 
Forceps, 341 

application of, 344, 345 

axis-traction, 350 

dangers of, 344 

in breech presentation, 350 

indications for, 343 

in face presentation, 350 

in occipito-posterior positions, 

350 
mechanical action of, 342 
Fossa navicularis, 21 
Fourchette, 20 

Funis, prolapse of. See Prolapsus 
funis. 

GALACTORRHCEA, 315 
Genital organs, ana torn y of, 
17 
external, anatomy of, 17 
internal, anatomy of, 29 
Graafian follicle, anatomy of, 44 
phenomena attending rupture 
of, 47 



382 



INDEX. 



HAXD-CLEAXIXG, technique 
of, 147 
Fiirbringer method of, 147 
permanganate method of, 147 
chlorinated soda method of, 
148 
Hegar's sign of pregnancy, 84 
Hemorrhage, accidental, 299 
from placenta previa, 292 
post-partum, 301 
secondary post-partum, 304 
Hemorrhages, the, 292 
Hydramnios, 209 

Hydrocephalus as a cause of dys- 
tocia, 280 
Hygiene of pregnancy, 93 
Hymen, anatomy of, 24 

IMPREGNATION, 50 

1 place, time, and mode of, 51 
Incubation of feeble infants, 186, 

336 
Induction of abortion, 337 

of premature labor, 330 
Insanity, puerperal, 314 
Involution, 172 

of uterus, 172 
Ischio-cavernosus muscle, 111 

TABIA majora, anatomy of, 19 
j minora, anatomy of, 20 
Labor, anomalies of, arising from 
accidents or disease, 282 
mechanism of, 240 
care of patient at close of, 169 
causes of onset of, 119 
duration of, 129 
management of, 130 
in flat pelvis, 252 
mechanism of first stage, 1 20 
second stage, 124 
third stage, 129 
mechanical factors of, 96 
norma], clinical and mechanical, 
definition of, phenomena of 
beginning, 119 
obstructed by anomalies of the 
hard parts, 245 
soft parts, 254 
pains, 120 
pathology of, 240 



Labor, perineal stage of, 128 
phenomena of beginning, 119 
physiology of, 96 
first stage of, 120 
second stage of, 124 
third stage of, 129 
duration of, 129 
precipitate, 240 
premature, 226 
prolonged, 240 
first stage, 240 
second stage, 243 
rule for predicting date of, 91 
stage of dilatation of, 120 
duration of, 123, 128 
expulsion of, 124 
stages of, 118 

laceration of passages, 162 
lacerations, cervical, 162 
of pelvic floor, 162 
treatment of, 163 
Lactation and nursing, 180 
Levator ani muscle, 108 
Linese albicantes, 78 
Liquor amnii, 54 

anomalies of, 208 
Lochia, 174 
Lubricants for obstetrician's hand, 

148 
Lying-in period, regulation of, 179 

MAMMARY changes in preg- 
nancy, 75 
diagnostic value of, as signs of 
pregnancy, 77 
glands, increased size of, as a 
sign of pregnancy, 75 
Mastitis, 315 
causes of, 315 
diagnosis of, 316 
treatment of, 316 
Membranes, artificial rupture of, 
153 
fcetal, 54 

management of, 161 
Menopause, 46 
Menstruation, 45 
Metritis, puerperal, 322 
Milk laboratories, 196 

secretion, pregnancy, 76 
Mons veneris, anatomy of, 17 
Montgomery' s follicles, 75 



INDEX. 



383 



Moulding of the foetal head in 

labor, 128 
Multiple pregnancy, 89 

VAVEL dressing of newborn 

1\ child, 187 

Nipples, care of, during pregnancy, 

94 

treatment of sore, 318 
Normal labor, clinical course and 

mechanism of, 118 
Nursing the newborn child, 188 
Nymplue, anatomy of, 20 

OBSTETRIC position, 154 
surgery, 330 

of the abdomen, 358 
Occipito-posterior position, 257 
Occiput, definition of, 113 
Oligohydramnios, 208 
Ophthalmia of newborn child, 203 
Os externum uteri, occlusion of, as 

a cause of dystocia, 255 
Ovaries, anatomy of, 41 
Oviducts. See Fallopian tubes. 
Ovulation, 45 
Ovum, anatomy of, 48 

development of impregnated, 51 

physiology of, 45 

PARAMETRITIS, puerperal, 
symptoms of, 322 
treatment of, 328 
Parovarium, 44 
Parturient axis, 111 
Passages, 97 

anomalies of, as affecting labor, 

245 _ 
laceration of, 162 
Passenger, anomalies of, as causes 
of dystocia, 257 
as a factor of labor, 112 
Pathology of pregnancy, 207 
Patient, obstetric, aseptic prepara- 
tion of, 149 
ante-partum, examination of, 

130^ 
examination of, during labor, 
150 
Pelvic deformity, diagnosis of, 250 
-floor, anatomy of, 106 . 
fascial sheets of, 107 



Pelvic floor, laceration of, 162 
treatment of, 163 

muscles of, 108 
prevention of lacerations of, 
157 
signs of pregnancy, 82 
soft parts, obstetric anatomv of, 
105 
Pelvimetry, 142-250 
external, 140 
internal, 142 
Pelvis, brim of, 98 
deformed, 245 

differences between male and fe- 
male, 104 
flattened and generallv con- 
tracted, 246 
funnel-shaped, 247 
justo-minor, 246 
kyphotic, 247 
measurements of, 103, 104 
Nregele oblique, 248 
narrowing of, from bonv tumors, 

250 # 
obstetric, anatomy of bony, 97 
ordinary oblique-ovate, 249 
osteomalacic, 250 
outlet of bony, 98 
planes, of, 100 
Roberts', 249 
simple flat, 246 
spondylolisthetic, 249 
Perineal body, 111 
Peritonitis, puerperal, symptoms 
of diffuse, 323 
treatment of, 327 
Phlegmasia alba dolens, svmptoms 
of, 323 
treatment of, 328 
Physiology of labor, 96 

of the puerperal state, 171 
Placenta and membranes, examina- 
tion of, at close of labor, 161 
anatomy of, 60 
anomalies of, 212 
degenerations of, 213 

white infarcts of, 213 
delivery of, 160 
development of, 63 
manual extraction of, 161 
previa, 212-292 
causes of, 293 



384 



INDEX. 



Placenta praevia, physical signs 
of, 294 
symptoms of, 293 
treatment of, 295 
removal of abnormally adherent, 

34 9. 
syphilis of, 212 

Placental stage, management of, 

160 

Polyhydramnios, 209 

Porro operation, 366 

indications for, 366 

steps of, 366 

Position of foetus, 117 

Post-partum chill, 171 

hemorrhage, 301 

causes of, 302 

diagnosis of, 302 

treatment of, 302 

secondary, 304 
visits, 175 
Posture of foetus, 118 
Powers, expelling, 96 

anomalies of, 240 
Pregnancy, abdominal signs of, 77 
care of nipples in, 94 
changes in cervix uteri in, 71 

uterus in, 69 
clothing in, 93 
duration of, 90 

ectopic. See jEctopic gestation, 
effects of, on maternal organism, 

69 
general changes in, 72 
hygiene of, 93 
mammary changes as signs of T 

75 
multiple, 89 

origin of, 89 
nausea as a sign of, 74 
pathology of, 207 
pelvic signs of, 82 
physical signs of, 75 
physiology of, 45 
ptyalism as a sign of, 74 
pulsation of uterine artery as a 

sign of, 86 
signs of, 73 
suppression of menses as a sign 

of, 73 
temperature of cervix uteri as a 

sign of, 86 



Premature labor, indications for, 
330 _ 
induction of, 330 
methods of, 331 
Presentation, breech, 266 
brow, 264 
face, 260 

methods for converting, into 
vertex, 263 
of foetus, 116 
shoulder, 275 
transverse, 275 
vertex. See Normal labor. 
Presentations, complex, treatment 

of, 277 
Prolapsus funis, 282 
diagnosis of, 283 
prognosis of, 284 
treatment of. 284 
Protuberances of foetal head, 113 
Ptyalism in pregnancy, 238 
Pruritus vulvae in pregnancy, 239 
Puberty, 46 

Pubic segment of pelvic floor re- 
traction of, during labor, 123 
Pudendum, anatomy of, 17 

vessels, lymphatics, and nerves 
of, 24/ 
Puerperal infection, 319 
diagnosis of, 321 
etiology of, 319 
special manifestations of, 321 
symptoms of special lesions 
" in, 322 

treatment of, 325 
insanity, 314 
causes of, 314 
prognosis of, 314 
treatment of, 314 
state, condition of uterus in, 172 
course and pbenomena of, 171 
management of, 175 
pathology of, 314 
physiology of, 171 
pulse-rate in, 171 
temperature in, 171 
Pyaemia, puerperal, 324 
treatment of, 329 

pEOTOCELE as a cause of dys- 

ll tocia, 254 

Retention of urine after labor, 176 



INDEX. 



385 



Retraction ring, 123 

of uterus at close of labor, 129 

OEMINAL fluid, 50 
O Septicaemia puerperal. See 
Puerperal infection, 
pure, symptoms of, 324 
Serous effusions into foetal cavities 

as a cause of dystocia, 282 
Shoulder presentation. See Trans- 
verse presentation. 
Signs of pregnancy, 73 

summary of diagnostic, 87 
Sinciput, definition of, 113 
Somatopleure, 53 
Souffle, funic, 80 

uterine, 81 
Spermatozoa, 50 
Sphincter ani ex tern us, 111 
Splanchnopleure, 53 
Stages of labor, 118 
Sudden death in childbed, 229 
Superfecundation, 90 
Superfcetation, 90 
Sutures of foetal head, 112 
Symphysiotomy, 367 

after-treatment of, 373 

indications for, 368 

method of operating in, 368 

results of, 367 

space gained in, 368 
Svmphvsis pubis, separation of, 
304 



TARDY involution of uterus, 
178 
Transverse presentation, 275 
causes of, 275 
diagnosis of, 276 
treatment of, 277 
Transversus perinei, 110 
Triangular ligament, 108 
Trunk, delivery of, 159 
Tumors, maternal, as causes of 
dystocia, 255 
foetal, as causes of dystocia, 282 
Twins, 278 

arrangement of membranes and 

placentas in, 90 
diagnosis of, 278 
interlocking, 280 
25 



UMBILICAL cord, anatomy of, 
63 
anomalies of, 213 
hemorrhage in newborn child, 

206 . 
infection in newborn child, 205 
Uretero-pyelitis in puerperal pe- 
riod, symptoms of, 325 
treatment of, 329 
Urethra, anatomy of, 28 
Urine, observation of the, during 

pregnancy, 94 
Uterus, anatomy of, 29 
arteries of, 37 
cavity of, 33 
changes in, during pregnancy, 

69 
developmental anomalies of, 256 
gravid, dimensions of, 70 

shape of, 70 

size of, 69 
intermittent contractions of, in 

pregnancy, 79 
inversion of, 286 

diagnosis of, 286 

etiology of, 286 

treatment of, 287 
involution of, after labor, 172 

tardy involution of, 178 
ligaments of, 36 
lymphatics of, 38 
nulliparous and parous, 35 
position of, 36 
regional divisions of, 32 
rupture of, 288 

diagnosis of, 290 

etiology of, 289 

prognosis of, 291 

treatment of, 291 
Uterine tumor of pregnancy, 
changes in, 83 

y AGIN A, anatomy of, 25 
V purplish color of, in preg- 
nancy, 82 
Vaginal examinations in second 

stage of labor, 154 
Varices of lower extremities in 

pregnancy, 239 
Veins, mammary enlargement of, 

during pregnancy, 76 
Version, 352 






386 



INDEX. 



Version, bipolar, 354 

external, 354 

indications for, 353 

internal, 357 
Vertex of fetal head, definition of, 
113 

presentation. See Normal labor. 
Vesicular mole, 210 
Vestibule, 22 



Villi, chorial, 58 
Vomiting of pregnancy. See Preg- 
nancy, nausea of. 
pernicious, 235 
etiology of, 235 
treatment of, 235 
Vulvar dressing at close of labor, 

169 
Vulvo- vaginal glands, 23 



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